Are Publicly Financed Dental Care Programs in Ontario Delivering the “Best Bang for their Buck? ”

1. Are Publicly Financed Dental Care Programs in Ontario Delivering the “Best Bang for their Buck?” E. Cardoso, V. Pilly, C. Quiñonez

2. Outline • Current situation • Strategies abroad • Conceptual framework • Multi-Criteria Decision Analysis (MCDA) tool • Strengths & Weaknesses • Conclusion

3. Current situation • Imbalance between financial resources and challenges • Increasing demand • Higher costs • Ethical dilemmas (Xie et al., 2011) • Sustainability of dental care programs • Recent call to increase access

4. Current situation • Challenge = Opportunity • Chase the “best bang for their buck” • Enhance process effectiveness & health outcomes • Mantra of “no new dollars” • Scrutinize the basket of dental care services • Resource allocation optimization(Elshaug et al., 2009) • Evidence and best practices

5. Strategies abroad Identify interventions with questionable outcomes (Garner & Littlejohns , 2011) Identify unsafe or ineffective services (Elshaug et al., 2012) Ethical principles for resource allocation (WHO,2004)

6. Conceptual framework • Decision support tool • Multi-Criteria Decision Analysis (MCDA) • Health Technology Assessment (HTA) • Evaluate existing or future practices • Evaluation phase or planning phase • Help decision action toward program objectives

7. Procedure Program Objectives Analysis Are programobjectives met? No Yes Analysis against need No Is procedure needed? Yes Do not fund Analysis against effectiveness No Is procedure effective? Yes Analysis against appropriateness No Is procedure appropriate? No Yes No Is it the only option? Yes Analysis deferred? Cost-effective analysis No Yes Professionalor Patient preference? No Yes Is it cost effective? Yes Procedure analysis Fund

8. Building the proposed MCDA • Various criteria listed and arranged in a hierarchical, priority-setting manner • Dental procedure must satisfy all listed decision criteriato be funded • Fails to meet criterion definition flagged not to be funded • Lacks evidence considered for evidence-based review

9. Procedure Program Objectives Analysis Are programobjectives met? No Yes Analysis against need No Is procedure needed? Yes Analysis against effectiveness No Is procedure effective? Yes Analysis against appropriateness No Is procedure appropriate? Yes

10. Program Objective Analysis • Procedure should: • Reflect on the founding principles of the program • Support the ultimate goals or programs objectives • Preserve the sustainability of the program

11. Need Analysis • Instrumental aspect of “need” • Not linked to ill health • “Minimum amount of resources required to exhaust capacity to benefit” (Culyerand Wagstaff, 1993) • Some needs ought to go unmet to be equitable (Culyer , 1998)

12. EffectivenessAnalysis • Achieved its outcome in real life setting(Guindo, 2012) • Strength of evidence for evidenced-based decision(Schanschieff , 1986) • How much improvement after the procedure is provided (Lavis, 1996) • Basis for ‘Approppriateness’ (Lavis, 1996)

13. AppropriatenessAnalysis • Effective for a particular patient or population • No efforts are made to balance benefits and costs yet (Lavis, 1996)

14. Cost-effectivenessAnalysis • Identify worth financing services from other options (Johnson et al., 2009) • Simplest criterion • Last in the hierarchy (Musgrove, 1999) • Other options for public funding (Musgrove, 1999)

15. Professional / patient preferences Analysis • Further analysis to avoid resource overutilization • Individual welfare is not for the scope of social responsibility (Wikler, 2002)

16. Procedure Program Objectives Analysis Are programobjectives met? No Yes Analysis against need No Is procedure needed? Yes Analysis against effectiveness No Is procedure effective? Yes Analysis against appropriateness No Is procedure appropriate? Yes

17. Do not fund No No Only option ? Yes Analysis deferred? No Cost-effective analysis Yes Yes Professional or Patient preference? No Yes Cost effective ? Yes Procedure analysis Fund

18. Strengths • Systematic and evidence-informed tool • Rational and transparent decision-making process • Identifies intrinsic values of each procedure • Drives program performance according to issues of sustainability

19. Weaknesses • Resistance from service providers • Resistance from funders • Centralized administration

20. Conclusion • Inequality in access to dental care asa public health issue • Sustainability of dental public health programs • Maximize health benefits as an ethical objective of the health care system • Proposed systematic tool • Evaluate current public oral health programs against their strategic goals • Push towards a stronger policy which includes vulnerable populations other than children

21. Thank You!

22. References • Culyer AJ. The morality of efficiency in health care — some uncomfortable implications. Health Econ 1992; 1: 7-18. • Culyer, A. Need-is a consensus possible? J. Med. Ethics 24, 77-80 (1998) • Elshaug, A., Moss, J.R., Littlejohns, P., Karnon, J., Merlin, T.L.& Hiller, J.E. (2009) Identifying existing health care services that do not provide value for money. MJA 190, 5: 269-73. • Elshaug, A. G., Watt, A. M., Mundy, L. & Willis, C. D. Over 150 potentially low-value health care practices: an Australian study. Med. J. Aust. 197, 556-560 (2012) • Garner, S. & Littlejohns, P. Disinvestment from low value clinical interventions: NICEly done? BMJ 343, d4519 (2011)

23. References • Guindo, L. A. et al. From efficacy to equity: Literature review of decision criteria for resource allocation and healthcare decisionmaking. Cost. Eff. Resour. Alloc 10, 9-7547-10-9 (2012) • Johnson, A. P. et al. Health technology assessment: a comprehensive framework for evidence-based recommendations in Ontario. Int. J. Technol. Assess. Health Care 25, 141-150 (2009) • Lavis, J. N. & Anderson, G. M. Appropriateness in health care delivery: definitions, measurement and policy implications. CMAJ 154, 321-328 (1996) • Musgrove, P. Public spending on health care: how are different criteria related? Health Policy 47, 207-223 (1999) • Ontario Association of Public Health Dentistry (2005) Preparing for change, Retreat April 27 - 29, 2005. Barrie: Vision Management Services, Ontario Association of Public Health Dentistry. • Quiñonez C, Sherret L, Grootendorst P, Shim MS, Azarpazhooh A, Locker D. An environmental scan of provincial/territorial dental public health programs. Office of the Chief Dental Officer, Health Canada. (2007) http://www.fptdwg.ca/English/e- environmental.html

24. References • Schanschieff S. Report of the committee of enquiry into unnecessary dental treatment, H M Stationery Office, Great Britain Department of Health and Social Security, England, 1986 • Wikler, D. Personal and social responsibility for health. Ethics Int. Aff. 16, 47-55 (2002) • World Health Organization (2004): Guidance on ethics and equitable access to HIV treatment and care. http://www.who.int/ethics/Guidance%20on%20Ethics% 20and%20HIV.pdf. • Xie, F. et al. Using health technology assessment to support evidence-based decision-making in Canada: an academic perspective. Expert Rev. Pharmacoecon Outcomes Res. 11, 513-521 (2011).