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Development of a Taxonomy for Health Care Decision-Making in Canada

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Development of a Taxonomy for Health Care Decision-Making in Canada

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    1. Eric Nauenberg, Ph.D.* Peter Coyte, Ph.D.* *Department of Health Policy, Management and Evaluation University of Toronto IRPP Conference Careful Consideration: Decision-Making in the Health Care System November 30th, 2004 Funded by the Canadian Health Services Research Foundation and the Ontario Ministry of Health and Long-Term Care as Regional Co-sponsors: RC-0861-06 Development of a Taxonomy for Health Care Decision-Making in Canada

    4. Disclaimer #2 “The content herein may [sic] shed some light on why the foot is connected to the head when it comes to decision-making, but the explanation is likely to be incomplete.” Source: Nauenberg E., The Health Economist’s Approach to Anatomy. Forthcoming, 2010.

    5. Purpose To develop a taxonomy to better understand health care decision-making Caveat: This taxonomy does not explain how decisions are made but rather helps explain the context in which decisions are made To help distinguish between advisory-making and decision-making The purpose of this paper is to develop a taxonomy for health care decision-making in Canada. Here, decision-making is seen to yield resource allocations. These resource allocations might privilege one service, one provider, one technology, or one setting over an array of alternative services, providers, technologies or settings. Rarely, if at all, would such decisions yield unambiguous gains for all participants in health care transactions. Consequently, health care decision-making occurs in a contested marketplace where the rules of engagement (that is, the evidence or tools used in negotiations) and the stakeholders that may legitimately participate are context specific. By identifying the components to such decision-making, we aim to describe what current decision-making practices are, to explore why they are what they are, and to develop valid and reliable predictive estimates of human and institutional behaviour. The purpose of this paper is to develop a taxonomy for health care decision-making in Canada. Here, decision-making is seen to yield resource allocations. These resource allocations might privilege one service, one provider, one technology, or one setting over an array of alternative services, providers, technologies or settings. Rarely, if at all, would such decisions yield unambiguous gains for all participants in health care transactions. Consequently, health care decision-making occurs in a contested marketplace where the rules of engagement (that is, the evidence or tools used in negotiations) and the stakeholders that may legitimately participate are context specific. By identifying the components to such decision-making, we aim to describe what current decision-making practices are, to explore why they are what they are, and to develop valid and reliable predictive estimates of human and institutional behaviour.

    6. Outline Conceptual Framework Simple Model of Health Care Exclusion: What’s in and what’s out of the Medicare basket? Jurisdictional Levels & Processes Used in Canadian Health Care Decision-Making Conclusion Our presentation will begin with an outline of the conceptual framework that guides our inquiry into health care decision-making. I will then proceed with a simple heuristic model of behaviour that is designed to highlight the factors that support the development, maintenance and enforcement of institutions of exclusion that here concerns health care services, providers, products and setting to be privileged by Medicare. We then review the jurisdictional levels and processes entailed in health care decision-making. Vignettes are used to illustrate and delineate various aspects of those decision-making processes. We close with a brief conclusion.Our presentation will begin with an outline of the conceptual framework that guides our inquiry into health care decision-making. I will then proceed with a simple heuristic model of behaviour that is designed to highlight the factors that support the development, maintenance and enforcement of institutions of exclusion that here concerns health care services, providers, products and setting to be privileged by Medicare. We then review the jurisdictional levels and processes entailed in health care decision-making. Vignettes are used to illustrate and delineate various aspects of those decision-making processes. We close with a brief conclusion.

    7. Conceptual Framework Deconstruct health care decision-making Define health care decision-making as opposed to health care advisory-making In order to develop our taxonomy, we first need to deconstruct some preconceived notions of health care decision making. This ‘deconstructive gesture’ criticizes “taken for granted” discourses associated with heath policy decision-making (eg the goal of improving the health of Canadians, advancing health service integration, or even containing government liability exposure), and this approach highlights the exclusionary role of decision-making in defining the Medicare basket, thereby assigning privilege. Specifically, each health care decision-making process results in health policies (at varying jurisdictional levels, whether macro, meso or micro), and these policies are but one of several “technologies”, including social and scientific discourse, cultural representation, and moral propositions, etc that may be used to engineer “appropriate” behavioral responses as a means of social control. (I.e. technologies define incentives, assign property rights and specify costs/benefits/responsibilities.) Taken together, these “technologies”, and the system of relations that may be established between these technologies, are the means used to code behavior, and to distinguish health care services, providers, technologies and settings that are included in or excluded from the Medicare basket. In order to develop our taxonomy, we first need to deconstruct some preconceived notions of health care decision making. This ‘deconstructive gesture’ criticizes “taken for granted” discourses associated with heath policy decision-making (eg the goal of improving the health of Canadians, advancing health service integration, or even containing government liability exposure), and this approach highlights the exclusionary role of decision-making in defining the Medicare basket, thereby assigning privilege. Specifically, each health care decision-making process results in health policies (at varying jurisdictional levels, whether macro, meso or micro), and these policies are but one of several “technologies”, including social and scientific discourse, cultural representation, and moral propositions, etc that may be used to engineer “appropriate” behavioral responses as a means of social control. (I.e. technologies define incentives, assign property rights and specify costs/benefits/responsibilities.) Taken together, these “technologies”, and the system of relations that may be established between these technologies, are the means used to code behavior, and to distinguish health care services, providers, technologies and settings that are included in or excluded from the Medicare basket.

    8. Health Care Exclusion: What’s In and What’s Out of Medicare? Consider a society with competing interests. Each group differs in their capacity to engage in and benefit from exclusionary actions. As long as the aggregate net benefit from exclusionary actions is sufficient, institutions will develop to support such actions (or efforts). In order to identify the factors that support the development, maintenance and enforcement of “institutions of health care exclusion”, a simple heuristic model of behaviour is presented.   Consider a society composed of two competing interests where the actions taken by one group (the dominant Alpha group) advance their interests, are costly for them to undertake, and may yield adverse consequences for “others” in society. In the context of today’s talk, these actions might concern the services to include in the Medicare basket, and the propensity and intensity of service allocation to insured residents, etc. Such efforts may assist in garnering greater access to scarce health care resources. Each group differs in their capacity to engage in and benefit from inclusionary or exclusionary activities. As long as the aggregate net benefit from these exclusionary activities is sufficient, institutions will develop to support such actions. In order to identify the factors that support the development, maintenance and enforcement of “institutions of health care exclusion”, a simple heuristic model of behaviour is presented.   Consider a society composed of two competing interests where the actions taken by one group (the dominant Alpha group) advance their interests, are costly for them to undertake, and may yield adverse consequences for “others” in society. In the context of today’s talk, these actions might concern the services to include in the Medicare basket, and the propensity and intensity of service allocation to insured residents, etc. Such efforts may assist in garnering greater access to scarce health care resources. Each group differs in their capacity to engage in and benefit from inclusionary or exclusionary activities. As long as the aggregate net benefit from these exclusionary activities is sufficient, institutions will develop to support such actions.

    9. Health Care Exclusion: What’s In and What’s Out of Medicare? Institutions that support exclusionary efforts are more likely to develop if: Those that benefit and the magnitude of their payoffs are large; Those that suffer adverse effects or the size of such effects are small; or Where the costs of engaging in exclusionary efforts are small. Furthermore, the predictions that flow from this model suggest that: Institutions that support exclusionary efforts are more likely to develop if:……………. These predictions suggest that the distributional consequences of resource allocations within health care plays an important role in generating incentives to pursue exclusionary activities.Furthermore, the predictions that flow from this model suggest that: Institutions that support exclusionary efforts are more likely to develop if:……………. These predictions suggest that the distributional consequences of resource allocations within health care plays an important role in generating incentives to pursue exclusionary activities.

    10. Health Care Decision-Making Health care decision-making is a context-specific process involving a range of stakeholders and a broad array of “evidence” that is designed to yield resource allocations that may differentially advance the interests of participants to health care transactions. Given our approach to health care decision-making as a process yielding resource allocations that further stakeholder interests, it might be useful to offer the following definition: Health care decision making……….. The four (4) important points to emphasize are: The context-specific nature of the decision-making process; The role of various stakeholders in that process; 3. The use of “evidence”, broadly defined to encompass information on effectiveness, efficiency and equity as well as expert or experiential opinion, as a tool for negotiation; and 4. The resulting resource allocations that need not advance the interests of all participants to health care transactions. Given our approach to health care decision-making as a process yielding resource allocations that further stakeholder interests, it might be useful to offer the following definition: Health care decision making……….. The four (4) important points to emphasize are: The context-specific nature of the decision-making process; The role of various stakeholders in that process; 3. The use of “evidence”, broadly defined to encompass information on effectiveness, efficiency and equity as well as expert or experiential opinion, as a tool for negotiation; and 4. The resulting resource allocations that need not advance the interests of all participants to health care transactions.

    11. Health Care Advisory-Making Within the public civil service and “arms length” advisory committees, advice on how to proceed with a decision is often developed and provided. This must not be confused with “decision-making” which often involves different factors.

    14. Two Major Components to Decision-Making Jurisdictional Level of Decision-Making from National to Individual Decision-Making; and Process of Decision Making from Centralized to Devolved Decision-Making. We believe that it is useful to decompose health care decision-making into two components: The first is based on the jurisdictional level of decision-making, that flows from the federal government down to decisions taken by individual care recipients, While the second is based on the degree to which the decision-making process is centralized, from centralized control with minimal participation by stakeholders, to devolved decision-making that offers the potential for greater involvement for each stakeholder group, albeit subject to their capacity to garner gains from participation. While the latter emphasizes involvement in the decision-making process, the former highlights the nested aspects of decision-making, whereby decisions at one level may act as constraints on decision-making at another level. We believe that it is useful to decompose health care decision-making into two components: The first is based on the jurisdictional level of decision-making, that flows from the federal government down to decisions taken by individual care recipients, While the second is based on the degree to which the decision-making process is centralized, from centralized control with minimal participation by stakeholders, to devolved decision-making that offers the potential for greater involvement for each stakeholder group, albeit subject to their capacity to garner gains from participation. While the latter emphasizes involvement in the decision-making process, the former highlights the nested aspects of decision-making, whereby decisions at one level may act as constraints on decision-making at another level.

    15. Nested Optimization Problems Characterized by a Cascade of Constraints Optimization decisions are subject to an array of constraints on the choice set or course of action. Each level of decision-making authority may impose constraints on each subsequent level. These restrictions on decision-making narrow the range of possibilities afforded to stakeholders. To elaborate on the nested aspects of decision-making, we might highlight the cascade of constraints that one jurisdictional level imposes on the set of decisions made at other levels. Its clear that Optimization decisions are subject…………………… For example, care recipients take actions, albeit sometimes partially informed ones or ones delegated to trusted agents to take on their behalf, that advance their life goals. These decisions are often constrained by technological, financial and other constraints on decision-making. Many of these constraints are context-specific; they are imposed by care providers, the regulatory environment, and other actors that participate in decision-making at various jurisdictional levels. To elaborate on the nested aspects of decision-making, we might highlight the cascade of constraints that one jurisdictional level imposes on the set of decisions made at other levels. Its clear that Optimization decisions are subject…………………… For example, care recipients take actions, albeit sometimes partially informed ones or ones delegated to trusted agents to take on their behalf, that advance their life goals. These decisions are often constrained by technological, financial and other constraints on decision-making. Many of these constraints are context-specific; they are imposed by care providers, the regulatory environment, and other actors that participate in decision-making at various jurisdictional levels.

    16. Jurisdictional Levels of Decision-Making Federal Provincial Regional (Regional Health Authorities) Transfer Agencies (i.e. hospitals, home health care agencies, etc.) Municipalities Individual Care Providers Individual Care Recipients There are at least seven (7) levels of decision-making that flows from the federal government, as the governing body for health care, to individual care recipientsThere are at least seven (7) levels of decision-making that flows from the federal government, as the governing body for health care, to individual care recipients

    17. Diagrammatically we may represent two dimensions of health care decision-making. The rows define the jurisdictional level of decision-making (or WHERE decision-making takes place), and the columns define the participants in the decision-making process (or WHO is involved in the decision-making process), The diagram, as drawn, abstracts from the two other important decision-making issues: the SUBJECT (or WHAT and WHEN of decision-making) and HOW decisions are made. The latter has three main dimensions, that emphasize the degree to which decision-making is: transparent; entails consultation; and is adversarial. For a complete depiction of decision-making these dimensions need to be incorporated into the diagram. We highlight three (3) stylized decision-making procesese, but we recognize that they are not exhaustive. Diagrammatically we may represent two dimensions of health care decision-making. The rows define the jurisdictional level of decision-making (or WHERE decision-making takes place), and the columns define the participants in the decision-making process (or WHO is involved in the decision-making process), The diagram, as drawn, abstracts from the two other important decision-making issues: the SUBJECT (or WHAT and WHEN of decision-making) and HOW decisions are made. The latter has three main dimensions, that emphasize the degree to which decision-making is: transparent; entails consultation; and is adversarial. For a complete depiction of decision-making these dimensions need to be incorporated into the diagram. We highlight three (3) stylized decision-making procesese, but we recognize that they are not exhaustive.

    18. Three Broad Sets of Health Care Decision-Making Processes “Closed-door/Top-down” decision-making: where decisions are taken by the governing body with control – constitutionally ordained or otherwise – over a particular decision without publicly transparent consultations with stakeholders. “Bilateral” decision-making: where decisions are jointly determined by both the governing body and stakeholders/other levels of government with some form of publicly visible process that may be combative or amenable to consensus-building. “Hands-off/Bottom-up” decision-making: where the governing body over a particular decision devolves authority to the stakeholders to make decisions by which they agree to abide. The three (3) broad sets of health care decision-making processes may be characterized in the following manner: First, “closed-door/top-down” decision-making, where decisions are taken…………………. By combining these three (3) sets of decision-making process with the seven (7) jurisdictional levels of decision-making yields the following matrix that offers a taxonomy for health care decision-making.The three (3) broad sets of health care decision-making processes may be characterized in the following manner: First, “closed-door/top-down” decision-making, where decisions are taken…………………. By combining these three (3) sets of decision-making process with the seven (7) jurisdictional levels of decision-making yields the following matrix that offers a taxonomy for health care decision-making.

    19. Taxonomy for Health Care Decision-Making This matrix, and its associated cells, provides a guide to health care decision-making in Canada. Each cell, highlights the jurisdictional level of decision-making, and simultaneously, describes the form & process used in decision-making. (The Where, Who & How of decision-making) In principle, this framework may be applied to decisions that pertain to health technology assessment or to other subjects in health care. (Concerning the What and When of decision-making) This matrix, and its associated cells, provides a guide to health care decision-making in Canada. Each cell, highlights the jurisdictional level of decision-making, and simultaneously, describes the form & process used in decision-making. (The Where, Who & How of decision-making) In principle, this framework may be applied to decisions that pertain to health technology assessment or to other subjects in health care. (Concerning the What and When of decision-making)

    20. Federal Role Promotion of health, setting and enforcing standards, and managing measures designed to increase accountability. Direct provision of insurance/services to population segments. Approval of safe and efficacious drugs - Food and Drug Act. Drug price regulation - Patented Medicines Prices Review Board. Leadership in health technology assessments with product listing recommends to the Provinces - Canadian Coordinating Office of Health Technology Assessment (CCOHTA), Common Drug Review (CCR), and the Canadian Expert Drug Advisory Committee (CEDAC). The roles played by the federal government pertain to the protection and promotion of health, setting and enforcing standards, and more recently, managing measures to increase accountability. Specific areas of responsibility include: direct insurance and service provision to segments of the population; ensuring safe and efficacious drugs; leadership in health technology assessments designed to recommend which products the provinces might list or insure; and regulating drug pricesThe roles played by the federal government pertain to the protection and promotion of health, setting and enforcing standards, and more recently, managing measures to increase accountability. Specific areas of responsibility include: direct insurance and service provision to segments of the population; ensuring safe and efficacious drugs; leadership in health technology assessments designed to recommend which products the provinces might list or insure; and regulating drug prices

    21. Provincial Role Provinces effectively define: services that will be publicly-funded, and hence, “medically necessary”; set fee schedules for provider reimbursement; and set global budgets for health care institutions. Provinces directly fund some hospital-based services, known in Ontario as “Priority Programs”, that lie outside of hospital global budget -- Cochlear implants (Bilateral decision-making) MRIs (Bilateral decision-making) PET scanners (Hands-off/Bottom-up decision-making) Genetic Testing (Absence decision-making rules for public funding, thereby raising concerns about access to care) The Provinces define: the Medicare basket, ie the range of services, providers, technologies and settings deemed “medically necessary”; the means by which transfer agencies and providers are financed and reimbursed; and insurance arrangements for population segments and for specific services and products, eg pharmacare, assistive devices, etc. Provinces directly fund some hospital-based services known in Ontario as “Priority Programs”. These funds are on top of hospital global budgets and often are directed to “high cost” and “high growth” areas. There are currently 15 such Programs in Ontario. Two interesting programs are Cochlear implants and MRIs. The Province funds the device portion of the implants, while the other surgical costs are funded through hospital global budgets. In the case of MRIs, the Province provides designated hospitals with operating funds to deliver MRI services, while the hospital and their local community are expected to finance the MRIs through fund-raising activities. Both of these Programs are examples of “bilateral decision-making”. In one case, the Province funds the technology while the operating costs are borne by the hospital, and in the other case, the Province covers the operating costs but not the acquisition costs of the technology. (Of course, at a recent First Minister’s meeting in February 2003, the Federal government made the commitment to offer Provinces funds that might be used to purchase equipment, such as MRIs, thereby aiding access and enlarging the decision-making pool to multi-lateral decision-making.) A very different process occurs for PET (Positron Emission Tomography) Scanners. These technologies are used to test for cancer, heart disease and Alzheimer’s disease, etc. By 2001, there were two machines in Canada used for patient care. The Quebec government fully funded the first machine, while the second machine is in Vancouver and requires patients to pay $2,500 per test. While there are no PET scanners available for patient care in Ontario, the Province has agreed that such private scanners may be introduced, but only as part of an evaluative process. This process will yield information that may be used to guide decision-making regarding public funding. Another difficult area concerns geno-technologies, including genetic testing. Provincial governments have yet to formally establish decision-making rules for genetic testing. Province are concerned with the diffusion of the technology, and the associated liability exposure for service provision in the event testing is positive, irrespective of the private or public funding of such tests. Indeed, if a genetic test indicates that someone is predisposed to a certain disease/disorder, then on-going disease surveillance and preventative treatment might reasonably argued to be “medically necessary”, and hence, publicly insurable.The Provinces define: the Medicare basket, ie the range of services, providers, technologies and settings deemed “medically necessary”; the means by which transfer agencies and providers are financed and reimbursed; and insurance arrangements for population segments and for specific services and products, eg pharmacare, assistive devices, etc. Provinces directly fund some hospital-based services known in Ontario as “Priority Programs”. These funds are on top of hospital global budgets and often are directed to “high cost” and “high growth” areas. There are currently 15 such Programs in Ontario. Two interesting programs are Cochlear implants and MRIs. The Province funds the device portion of the implants, while the other surgical costs are funded through hospital global budgets. In the case of MRIs, the Province provides designated hospitals with operating funds to deliver MRI services, while the hospital and their local community are expected to finance the MRIs through fund-raising activities. Both of these Programs are examples of “bilateral decision-making”. In one case, the Province funds the technology while the operating costs are borne by the hospital, and in the other case, the Province covers the operating costs but not the acquisition costs of the technology. (Of course, at a recent First Minister’s meeting in February 2003, the Federal government made the commitment to offer Provinces funds that might be used to purchase equipment, such as MRIs, thereby aiding access and enlarging the decision-making pool to multi-lateral decision-making.) A very different process occurs for PET (Positron Emission Tomography) Scanners. These technologies are used to test for cancer, heart disease and Alzheimer’s disease, etc. By 2001, there were two machines in Canada used for patient care. The Quebec government fully funded the first machine, while the second machine is in Vancouver and requires patients to pay $2,500 per test. While there are no PET scanners available for patient care in Ontario, the Province has agreed that such private scanners may be introduced, but only as part of an evaluative process. This process will yield information that may be used to guide decision-making regarding public funding. Another difficult area concerns geno-technologies, including genetic testing. Provincial governments have yet to formally establish decision-making rules for genetic testing. Province are concerned with the diffusion of the technology, and the associated liability exposure for service provision in the event testing is positive, irrespective of the private or public funding of such tests. Indeed, if a genetic test indicates that someone is predisposed to a certain disease/disorder, then on-going disease surveillance and preventative treatment might reasonably argued to be “medically necessary”, and hence, publicly insurable.

    22. Provincial Role: Prescription Drugs The advent of a common drug review process at the federal level has relegated provincial committees to advice on “how to list” (i.e. general use, limited use, etc.) rather than “what to list”. (Closed-door/Top-down decision-making) Recent advice from CEDAC to not fund the first-in-therapeutic class treatments--Replagal and Fabrazym--for Fabry Disease will be test of cohesiveness of provinces in responding to a “thumbs down” advisory from this process. Beta Interferon – available in Ontario under a Section 8 process, where a prescriber makes a case-by-case application to the Drug Quality and Therapeutics Committee (DQTC) for approval compared to Quebec where the drug is fully funded. The introduction of a common drug review process at the federal level, while advisory, has relegated provincial committees to advice on “how to list” (i.e. general use, limited use, etc) rather than “what to list”. Thus, decisions regarding drug coverage is an example of closed-door/top-down decision-making even though there is input from stakeholders. For example, in the case of Beta Interferon which is used in the treatment of Multiple Sclerosis, while the drug was approved by the Federal Health Protection Branch in 1995, it is only available in Ontario under a Section 8 process where a prescriber may make application to the Drug Quality and Therapeutics Committee (DQTC). In contrast, in Quebec the drug is fully funded. The introduction of a common drug review process at the federal level, while advisory, has relegated provincial committees to advice on “how to list” (i.e. general use, limited use, etc) rather than “what to list”. Thus, decisions regarding drug coverage is an example of closed-door/top-down decision-making even though there is input from stakeholders. For example, in the case of Beta Interferon which is used in the treatment of Multiple Sclerosis, while the drug was approved by the Federal Health Protection Branch in 1995, it is only available in Ontario under a Section 8 process where a prescriber may make application to the Drug Quality and Therapeutics Committee (DQTC). In contrast, in Quebec the drug is fully funded.

    23. Provincial Role: Physician/Hospital Services Negotiated settlements between physicians and provinces (Bilateral decision-making) Future of this process is now being tested in Ontario due to the events of the past week. Quebec’s Bill 114 is an example of a closed-door/top-down decision making process where control occurs through back-to-work legislation. Most provinces have adopted a hands-off/bottom-up decision-making process regarding requests for out-of-province/out-of-country treatment Provider remuneration and the services covered under provincial insurance plans are largely determined though negotiation between the organizations that represent providers (whether nurses, physicians, hospitals, community pharmacists, etc) and those representing insurers (whether provincial governments, regional authorities, etc). This process is often akin to bilateral decision-making, with a somewhat open and transparent process. Quebec’s Bill 114 is an example of a closed-door/top-down decision making process where physicians may be ordered by Regional Health Boards to work in Emergency Departments if such Departments are threatened. Regarding out-of-province and out-of-country health service claims, Ontario has adopted a hands-off/bottom-up decision-making process in order to assess medical necessity when reviewing physician requests. Claims are referred to outside experts reporting to the Ministry of Health, normally an OHIP consultant. If the Ministry expert differs from the referring physician’s opinion, the case goes through a Medical Review Board hearing for further input before a final determination.Provider remuneration and the services covered under provincial insurance plans are largely determined though negotiation between the organizations that represent providers (whether nurses, physicians, hospitals, community pharmacists, etc) and those representing insurers (whether provincial governments, regional authorities, etc). This process is often akin to bilateral decision-making, with a somewhat open and transparent process. Quebec’s Bill 114 is an example of a closed-door/top-down decision making process where physicians may be ordered by Regional Health Boards to work in Emergency Departments if such Departments are threatened. Regarding out-of-province and out-of-country health service claims, Ontario has adopted a hands-off/bottom-up decision-making process in order to assess medical necessity when reviewing physician requests. Claims are referred to outside experts reporting to the Ministry of Health, normally an OHIP consultant. If the Ministry expert differs from the referring physician’s opinion, the case goes through a Medical Review Board hearing for further input before a final determination.

    24. Provincial Role: Home Care Services Devolution of responsibility to regional health authorities or Community Care Access Centres (CCACs) in Ontario. Since 1997, CCACs divested themselves of direct service providers and allocated service contracts on the basis of a competitive bidding process. (Hands-off/bottom-up decision-making) Community Care Access Corporations Act of 2001 returned some control to the province, advanced CCAC accountability, and maintained a hands-off/bottom-up relationship with direct service providers. Most provinces have devolved responsibility for the allocation and funding of home care services to regional health authorities, or in the case of Ontario, to transfer agencies called Community Care Access Centres (CCACs). Since 1997, there has been a shift away from the direct provision of care by CCACs towards a Request for Proposals process (or competitive bidding process) in the allocation of service contracts. This shift represents a hands-off/bottom-up decision-making process. Despite significant home care funding increases, there was recognition that CCACs lacked the managerial acumen and infrastructure to rectify service inconsistencies and fiscal imbalance. The Ontario government reclaimed some control through passage of the Community Care Access Corporations Act that sought to advance CCAC accountability for funding allocations, but maintained a “hands-off/bottom-up decision-making” relationship with direct service providers.Most provinces have devolved responsibility for the allocation and funding of home care services to regional health authorities, or in the case of Ontario, to transfer agencies called Community Care Access Centres (CCACs). Since 1997, there has been a shift away from the direct provision of care by CCACs towards a Request for Proposals process (or competitive bidding process) in the allocation of service contracts. This shift represents a hands-off/bottom-up decision-making process. Despite significant home care funding increases, there was recognition that CCACs lacked the managerial acumen and infrastructure to rectify service inconsistencies and fiscal imbalance. The Ontario government reclaimed some control through passage of the Community Care Access Corporations Act that sought to advance CCAC accountability for funding allocations, but maintained a “hands-off/bottom-up decision-making” relationship with direct service providers.

    25. Regional Decision-Makers (Regional Health Authorities) The following RHA processes are normally characterized as “hands-off/bottom-up” decision-making: Internal allocation by transfer agencies of financial resources to meet volume/deliver expectations; Fundraising activities for internal use by institutions; Monitoring of quality measures against regional standards; Staffing patterns and allocation to meet needs. Many opportunities for local sabotage of regional priorities and initiatives by swaying public opinion. Contracting-out to private-for-profit clinics. All provinces have some form of regionalization, except Ontario, with the impetus to contain costs and enhance service integration. The following Regional Health Authority decision-making processes are normally hands-off/bottom-up: Internal allocation by transfer agencies of financial resources to meet volume/deliver expectations; Fundraising activities for internal use by institutions; Monitoring of quality measures against regional standards; and Staffing patterns and allocation to meet needs. Within regional structures, some suggest that there are few examples of local control, but many opportunities for local sabotage of regional priorities by swaying public opinion. For example, at the Winnipeg Regional Health Authority there is a single drug formulary that is not uniformly popular across hospitals as it does not recognize institutional differences. Contracting-out to private-for-profit clinics has been advanced by the Vancouver Coastal Health Authority on the basis of competitive bids in order to reduce waiting times for various surgeries. All provinces have some form of regionalization, except Ontario, with the impetus to contain costs and enhance service integration. The following Regional Health Authority decision-making processes are normally hands-off/bottom-up: Internal allocation by transfer agencies of financial resources to meet volume/deliver expectations; Fundraising activities for internal use by institutions; Monitoring of quality measures against regional standards; and Staffing patterns and allocation to meet needs. Within regional structures, some suggest that there are few examples of local control, but many opportunities for local sabotage of regional priorities by swaying public opinion. For example, at the Winnipeg Regional Health Authority there is a single drug formulary that is not uniformly popular across hospitals as it does not recognize institutional differences. Contracting-out to private-for-profit clinics has been advanced by the Vancouver Coastal Health Authority on the basis of competitive bids in order to reduce waiting times for various surgeries.

    26. Hospitals and Other Transfer Agencies Through their global budgets, along with additional funding through fundraising or charitable contributions, hospitals must decide on the adoption of new technologies through their respective pharmacy and therapeutics committee. (Closed-door/top-down decision-making) While most health care delivery is based on resource allocations by provincial and territorial governments, a portion of funds are often devolved to transfer agencies, such as hospitals, home care agencies and long-term care institutions. In the case of technology acquisitions and formulary determination, hospitals often base such decisions on internal pharmacy and therapeutics committee(s). While some of these decisions may entail public consultation, most decisions are made without publicly transparent consultation and thus, are reflective of a “closed-door/top-down” decision-making process. While most health care delivery is based on resource allocations by provincial and territorial governments, a portion of funds are often devolved to transfer agencies, such as hospitals, home care agencies and long-term care institutions. In the case of technology acquisitions and formulary determination, hospitals often base such decisions on internal pharmacy and therapeutics committee(s). While some of these decisions may entail public consultation, most decisions are made without publicly transparent consultation and thus, are reflective of a “closed-door/top-down” decision-making process.

    27. Individual Care Providers & Care Recipients Health care decision-making processes are shifting towards more “bilateral” processes and away from more “closed-door/top-down” processes as patients become more informed through various media. Different views on the merits of this development exist, particularly if the capacity to benefit from shared decision-making is unevenly distributed in society. While individual care providers have historically been responsible for the most routine medical decisions, such as diagnosis, treatment selection and referral, care recipients have increasingly become more involved in health care decision-making. This shift in the decision-making process reflects a move from “closed-door/top-down decision-making” to “bilateral decision-making”. Some more consumer-based movements might even be termed “hands-off/bottom-up decision-making”. Different views on the merits of this development exist. Some highlight the potentially harmful effects of these changes to the decision-making process if the capacity to benefit from such shared decision-making is unevenly distributed in society. In this way some may benefit more than others and often at the expense of others. While individual care providers have historically been responsible for the most routine medical decisions, such as diagnosis, treatment selection and referral, care recipients have increasingly become more involved in health care decision-making. This shift in the decision-making process reflects a move from “closed-door/top-down decision-making” to “bilateral decision-making”. Some more consumer-based movements might even be termed “hands-off/bottom-up decision-making”. Different views on the merits of this development exist. Some highlight the potentially harmful effects of these changes to the decision-making process if the capacity to benefit from such shared decision-making is unevenly distributed in society. In this way some may benefit more than others and often at the expense of others.

    28. Conclusion (I) We offer a taxonomy for health care decision-making that highlights the constraints under which decisions are made. In 2003, national health expenditures were estimated to be $121.4 B; $3,839 per capita; & 10% of GDP (CIHI, 2003) growth in expenditures is well in excess of growth of overall economy Increase health service accountability & more centralized decision-making are responses to insatiable appetite for health care services. The limited role for cost-effectiveness analysis under the Canada Health Act which emphasizes medical necessity Is it time to change to standard of “reasonable and necessary”? Pressure from private markets and the relationships between public and private markets In 2003, health expenditures were $121.4 billion; $3,839 per capita; and 10% of Gross Domestic Product. Over the last 44 years, we have witnessed in Canada a 32-fold increase in per capita health expenditures, while only a 7-fold increase in the consumer price index. Such dramatic expenditure increases, in the absence of incremental cost and outcome measures, is not only unsustainable, it’s unethical! Calls for greater health service accountability and the shift towards more central control over health care decision-making processes is a consequence of these environmental changes in this most terminal, of terminal industries. While a greater role for economic evaluation methods might enhance utilitarian goals, there is unease, skepticism and a loss of political capital in reliance on such simple solutions, particularly solutions that advance the public interest rather than “narrow’ stakeholder interests. We have offered a taxonomy for health care decision-making that highlights the WHERE, WHO & HOW of health care decision-making that may be applied to the day-to-day decisions concerning: WHAT and WHEN. This taxonomy emphasizes the nested aspects of decision-making, whereby decisions at one level may act as constraints on decision-making at another level, thereby offering the potential for control over decision-making. Vignettes are used to illustrate and delineate various aspects of health care decision-making. In 2003, health expenditures were $121.4 billion; $3,839 per capita; and 10% of Gross Domestic Product. Over the last 44 years, we have witnessed in Canada a 32-fold increase in per capita health expenditures, while only a 7-fold increase in the consumer price index. Such dramatic expenditure increases, in the absence of incremental cost and outcome measures, is not only unsustainable, it’s unethical! Calls for greater health service accountability and the shift towards more central control over health care decision-making processes is a consequence of these environmental changes in this most terminal, of terminal industries. While a greater role for economic evaluation methods might enhance utilitarian goals, there is unease, skepticism and a loss of political capital in reliance on such simple solutions, particularly solutions that advance the public interest rather than “narrow’ stakeholder interests. We have offered a taxonomy for health care decision-making that highlights the WHERE, WHO & HOW of health care decision-making that may be applied to the day-to-day decisions concerning: WHAT and WHEN. This taxonomy emphasizes the nested aspects of decision-making, whereby decisions at one level may act as constraints on decision-making at another level, thereby offering the potential for control over decision-making. Vignettes are used to illustrate and delineate various aspects of health care decision-making.

    29. Conclusion (II) Pressure from higher government levels limits decision-making on the government (or other decision-maker) below. Changing relationship between physicians and patients. The future: role of LHINs in--and impact upon--decision-making: Maybe different than RHAs given differences in governance structures

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