Transcript Development of a Taxonomy for Health Care Decision Making in

Development of a Taxonomy for Health
Care Decision-Making in Canada
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
Disclaimer
The content herein reflects the
observations and opinions of the
authors and in no way reflect the official
positions of the Ontario Ministry of
Health and Long Term Care (MOHLTC),
the CHSRF, nor any other decisionmaking body.
Disclaimer #2
“The content herein may [sic] shed
some light on why the foot is connected
to the head when it comes to decisionmaking, but the explanation is likely to
be incomplete.”
Source: Nauenberg E., The Health Economist’s
Approach to Anatomy. Forthcoming, 2010.
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
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
Conceptual Framework
• Deconstruct health care decision-making
• Define health care decision-making as
opposed to health care advisory-making
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).
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.
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.
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.
Advisory Example: OHTAC Process for Reviewing Health Technologies
Application
to OHTAC
through
MAS for
review
Application
with
Sponsorship
Preassessment
for OHTAC
prioritisation
HT
evidence
based
policy
analysis
and
Ontario
based data
analysis
[16 weeks]
MAS
Recommend
•Implement
•Not
implement
•Re-visit
•Field
evaluation
•Registry
study
OHTAC
MOHLTC
response
and
policy
decision
within 60
days.
Appeals
process
MOHLTC
Medical Advisory Secretariat HTPA Process
Prioritisation:
•Description
•Priority score
•OHTAC
Prioritisation
MAS
HTPA
Unit
Systematic
Review Effectiveness
Economic
Analysis
•Search
databases
•Selection
criteria
•Analysis
•Consult
experts,
industry
•Budget
impact
•CEA
•Cost
avoidance
Expert
Review of
HTPA
–Published
systematic
review
available
Policy
Options &
Ontario
Specific
Analysis
OHTAC:
Critical Review
•Ethical,
legal,
regulatory,
systems
implications
•Options
•Recommend
to DM
•Disseminate
on Website
Synthesis
Review
MAS HTPA
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.
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.
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
Components of the
Decision-Making Process
Centralized
Level of Decision-Making
Macro
Meso
Micro
Devolved
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.
Taxonomy for Health Care Decision-Making
Decision-making
process
Level of
Decision-making
Federal
Macro
Provincial
Regional
Meso
Municipal
Transfer Agency
Care Provider
Micro
Care Recipient
Centralized
Closed-door/
Top-down
Devolved
Bilateral
Hands-off/
Bottom-up
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).
Provincial Role
• Provinces effectively define: services that will be publiclyfunded, 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)
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.
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-ofprovince/out-of-country treatment
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. (Handsoff/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.
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.
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)
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.
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 decisionmaking 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
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