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

1. Priority Setting: Beyond Evidence-based Medicine and Cost-effectiveness Analysis Douglas K. Martin, PhD 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

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

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

4. Evidence-based Medicine & Cost-effectiveness Analysis • Dominant tradition; HTA = TAH • Technical problems • 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 • PaussJensen, Singer, Detsky. Ontario’s Formulary Committee How Recommendations are Made. Pharmacoeconomics (2003). • “Complex economic analyses played a limited role.” • Helpful but limited; necessary but not sufficient

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

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

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

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

9. Where we are going • “Simple solutions” on one hand and “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

10. Criteria & Process: Parameters of Success • Competing goals and multiple stakeholder relationships • Efficiency considerations or technical solutions limited influence, not sufficient • 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. • Underscores the importance of procedural fairness to secure socially acceptable priority setting decisions and to ensure public accountability. Gibson, Martin, Singer. BMCHS, 2004

11. Informal Networks of Deliberation • 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’

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

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

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

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

16. Database of Learning

17. Priority Setting Social Policy Learning • Make ‘private’ decisions public • Educative function • Body of ‘case law’; institutional reflective equilibrium • Iterative - improves over time

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

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