Priority Setting in Health Care Arindam Basu [email protected] Priority Setting in Health Care Arindam Basu [email protected] 8th April, 2015 University of Canterbury 

Priority Setting in Health Care Arindam Basu [email protected] What Shall We Cover today? Start with a Case Study Examine Issues with Priority Setting in Health Care Learn Aspects of how priority setting exercises are done Discuss how to evaluate whether the priority setting was done well 

Priority Setting in Health Care Arindam Basu [email protected] Case Study Figure: casestudy 

Priority Setting in Health Care Arindam Basu [email protected] Your constraints You will make the payment You are allowed to pay only $1000 Each option costs exactly $1000 You cannot split payment You will need to justify your option 

Priority Setting in Health Care Arindam Basu [email protected] What would you do? Which procedure you will fund? Which two children will sit out? What were the problems for you? 

Priority Setting in Health Care Arindam Basu [email protected] Your final decision may have depended on 1 The value of long-term returns versus short-term health gain 2 Gaining Insights into the problems 3 The different options available and their consequences 

Priority Setting in Health Care Arindam Basu [email protected] Relationship of this exercise to Priority Setting Limited resources unlimited wants Rational choice for exclusion of people (some will lose) 

Priority Setting in Health Care Arindam Basu [email protected] Characteristics of priority setting Applied to a broad range of policy issues Cost-containment at a macroeconomic level Clinical practice guidelines for the individual doctor Explicit or Implicit Criteria Used Has Ethical, Social, Financial Implications 

Priority Setting in Health Care Arindam Basu [email protected] Principles of Priority Setting (Hasman, 2006) Rule of rescue principle – treat people in immediate pain and suffering Health maximisation – allocate resources so that aggregate health of society is maximised Life-time equality – Reduce differences in peoples life-time experience of health. 

Priority Setting in Health Care Arindam Basu [email protected] Accountability for Reasonableness (A4R, Norman Daniels) Transparency about grounds for decisions Acceptability of Rationale all can accept as relevant to meeting health needs Decisions can be Revised Challenges Can Be Addressed Empirically Feasible 

Priority Setting in Health Care Arindam Basu [email protected] Importance of priority setting exercises Limited Resources Unlimited Demands Ethical Imperatives Time and resource constraints 

Priority Setting in Health Care Arindam Basu [email protected] How are priority setting exercises conducted? 

Priority Setting in Health Care Arindam Basu [email protected] Categories of Care Model First, broadly define general categories of care Next, allow stakeholders to make more specific decisions with the categories Used in New Zealand in 1990 

Priority Setting in Health Care Arindam Basu [email protected] Pros and Cons of Categories of Care Limits the effect of opposition to prioritisation Lacks specificity so that targets cannot be easily set Inefficient allocation of resources Potentially creates conflicts of interest. 

Priority Setting in Health Care Arindam Basu [email protected] Explicit Criteria Model List basic package of services to provide or finance Base the package on a set of agreed criteria The criteria can include community needs, preferences, economic evaluations, others Categories of Care PLUS Explicit Criteria 

Priority Setting in Health Care Arindam Basu [email protected] Pros and cons of Explicit Criteria Relatively Straightforward Benefits from the Priority Setting Exercise is Well Formulated Difficult to achieve in Practice due to Conflicts 

Priority Setting in Health Care Arindam Basu [email protected] Guidelines Model Assess technical efficacy of different interventions Efficacy == How well Technology Works in Ideal circumstances Provide Guidelines to the practitioners and patients to follow. Clearly defines when services are technically beneficial Does not include the economic component, community preferences, and values 

Priority Setting in Health Care Arindam Basu [email protected] Models Based on Other Models Collect information on the costs and benefits of all the interventions to be considered Create a common currency for measuring and comparing the benefits Create packages using models and assessments, e.g., burden of disease and cost-effectiveness Social preferences can influence how the different benefits are combined and valued 

Priority Setting in Health Care Arindam Basu [email protected] Pros and Cons Combines qualitative and quantitative methods Needs a lot of data Does not take into account the economic rationale for public intervention. 

Priority Setting in Health Care Arindam Basu [email protected] Overview of Priority Setting Exercises Figure: stepwise 

Priority Setting in Health Care Arindam Basu [email protected] Steps of Priority Setting Exercises Identify stakeholders who will conduct the prioritisation exercise Identify the list of services or packages to be developed and administered Identify and list the criteria on which these need to be based Prepare a weighting system (vote counting or otherwise) Create a matrix of interventions versus criteria Assign rank orders to the matrix 

Priority Setting in Health Care Arindam Basu [email protected] Stakeholders Healthcare Providers Epidemiologists Health Economists Donors, Insurers, and Payers Politicians Activists and Patient Advocates 

Priority Setting in Health Care Arindam Basu [email protected] Criteria for Developing Packages and Setting Priorities What Criteria Should be Used? 

Priority Setting in Health Care Arindam Basu [email protected] PS should be based on a Systems Approach Many services provided delivered at different levels Must consider all relevant levels 

Priority Setting in Health Care Arindam Basu [email protected] PS should take into account Budget Constraints How expenditures are directed can be challenging Budget may have to be changed Staffing will be affected Some services will be taken off as a result of the prioritisation Does the system have resilience to adapt to that change? What are some political implications? 

Priority Setting in Health Care Arindam Basu [email protected] PS should take into account Transition Costs Developing a package of services or benefits may involve changing focus Difference in the costs of now and when packages developed 

Priority Setting in Health Care Arindam Basu [email protected] PS must consider the issue of Risk Pooling of Health Care Some health conditions are rare and too costly for most uninsured individuals Different levels of Risks and different combinations of risks are balanced by Insurance Payers should be resilient to the risk pooling Role of public intervention so that the markets do not fail 

Priority Setting in Health Care Arindam Basu [email protected] PS must recognise that Health is Public Good 

Priority Setting in Health Care Arindam Basu [email protected] Public Health as public good Public Health facilities consumed by people at the same time No rivalry or competition (non-rival in consumption) Providers cannot prevent people from enjoying good health (non-exclusionary) Pure public goods (public health information), should receive more attention 

Priority Setting in Health Care Arindam Basu [email protected] PS must recognise Externalities For some goods and services, cost and/or benefits to society are different than those to the producers and consumers directly involved in the exchange Some health services are private but they produce benefits to society beyond the direct benefits to the consumers Markets will most likely under-produce the good or service with a strong positive benefit externality as compared to the socially optimal level of production Therefore, if externalities are large, public attention will be required 

Priority Setting in Health Care Arindam Basu [email protected] PS should consider Burden of Disease 

Priority Setting in Health Care Arindam Basu [email protected] Review of the Burden of Disease Concept Loss based measure of How much disease and disease impact is present Common measure: DALYs (Disability adjusted life years) DALY = Years of Life Lost + Years Lived with Disability 

Priority Setting in Health Care Arindam Basu [email protected] Pros and Cons of Using BoD Uses a common currency Numbers can be stratified by population subgroups Provides useful advocacy information for the different groups Misrepresenting true burden by those that cannot use the numbers for advocacy. 

Priority Setting in Health Care Arindam Basu [email protected] PS must take into account issues of Health Equity 

Priority Setting in Health Care Arindam Basu [email protected] Health Equity The level or the amount of services received should not depend on the social status of the client but on biological or clinical needs Could involve income categorisation, gender, age groups, tribal groups, social classes, or regional clusters 

Priority Setting in Health Care Arindam Basu [email protected] Measures of Equity Health and family welfare outcomes Access to goods and services, or financial burden Advocates assign higher value to services or goods that would more likely benefit the group they are advocating for. 

Priority Setting in Health Care Arindam Basu [email protected] PS should consider Cost Effectiveness of Interventions 

Priority Setting in Health Care Arindam Basu [email protected] Cost Effectiveness of Interventions Takes into account relative effectiveness of interventions Relative Costs of the interventions Costs in terms of time and logistics Rank Order the interventions on the basis of cost effectiveness Measure of Efficiency 

Priority Setting in Health Care Arindam Basu [email protected] Efficacy, Effectiveness and Efficiency Efficacy. – Benefit under ideal circumstances (RCTs) Effectiveness. – Benefits under regular situations (Other forms) Efficiency. – Benefits with respect to resources consumed or utilised 

Priority Setting in Health Care Arindam Basu [email protected] Concept of Losers in Prioritisation Prioritisation also means that some groups will not be benefitted Groups that are not benefitted as a result of prioritisation are important Accounting for the Losers will enable evaluation of the Priority Setting Exercise 

Priority Setting in Health Care Arindam Basu [email protected] Ways to identify which groups were not benefited as a result of PS Intuitive. – Those with least voice Squeaky Wheel Gets the Grease Systematic. – Follow the Money and Benefit Incidence Analysis 

Priority Setting in Health Care Arindam Basu [email protected] Systematic Ways to identify Losers in the system 

Priority Setting in Health Care Arindam Basu [email protected] Follow the Money Analysis Review Budgets Explore in details the different allocations for different strata of population 

Priority Setting in Health Care Arindam Basu [email protected] Check where the resources are flowing (Examples) Are resources flowing to address diseases of the poor? Are resources flowing to preventive and promotive services? Are resources flowing to Behaviour Change Communications? Are resources flowing to appropriate levels of care delivery? 

Priority Setting in Health Care Arindam Basu [email protected] Use Deciles (as in NZ) for Geographic Targeting Are resources flowing to regions with the most need? Are resources flowing to rural areas or to poor urban areas? 

Priority Setting in Health Care Arindam Basu [email protected] Benefit Incidence Analysis An analysis that looks into who are beneficiaries and where the allocation goes Who are using the services What is the cost to the government of making the services available Data Intensive 

Priority Setting in Health Care Arindam Basu [email protected] Data Required for Benefit Incidence Analysis A detailed household survey that includes information on health services use (preferably by the level of care) and allows for grouping individuals by socio-economic characteristics (such as wealth or residence). The second type of information needed is the unit cost to the government of providing the different types of services (typically a hospital overnight stay or an out-patient consultation at the different levels of facilities) 

Priority Setting in Health Care Arindam Basu [email protected] Steps of Benefit Incidence Analysis 1 Group users by socioeconomic strata (income, deciles, ethnicity) 2 Determine service use by stratum 3 Calculate the unit cost for the service 4 Subtract the out-of-pocket fees from cost 5 Multiply the net unit cost by the group service use to determine group benefit 

Priority Setting in Health Care Arindam Basu [email protected] Summary