Creating a Framework for Public Dialogue About Health Care Allocation Decisions

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Creating a Framework for Public Dialogue About
Health Care Allocation Decisions

• Community Health Graduate Seminar
• January 14th, 2004
• Doreen Neville, ScD

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Outline

• Research Team
• Background
• Purpose and Objectives
• Methods
• Timelines
• Acknowledgements
• Questions/Discussion

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Research Team

• Tom Rathwell, PhD, Dalhousie
• Raisa Deber, PhD, U of T
• Doreen Neville, ScD, MUN
• Larry Nestman, PhD, Dalhousie
• Nuala Kenny, MD, Dalhousie
• Patricia Conrad, PhD candidate, U of T
• Thomas Ward, Lead Decision Maker, NS
• Robert Thompson, Lead Decision Maker, NL
• Eric Nauenberg, Lead Decision Maker, Ontario

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Research Team

• Roger Chafe, Graduate Student, ARTC, MUN
• Heather Chappell, Graduate Student, U of T
• Christine Joffre, PhD, Research Assistant,
  Dalhousie

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Background

• The CHA requires that all medically necessary
  hospital and physician services be publicly
  financed, but it is silent on the issue of
  coverage for out of hospital services such as
  home care, rehabilitation and pharmaceuticals
• New federal funding in the areas of home care
  and catastrophic drug coverage not withstanding,
  provinces still have the power to define the
  scope of medically necessary services

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Background (continued)

• New technologies and drugs are further taxing the
  resources of provincial health care systems
• Considerable variation in access and
  comprehensiveness already exists across Canada
• A number of review panels and commissions have
  implemented across Canada in the past decade to
  review and propose strategies for renewing
  Medicare

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Background (continued)

• Acceptable approaches to deciding what services
  should be included in the publicly funded
  Medicare basket are needed by decision makers at
  all levels in the health system
• - federal and provincial governments
• - regional health authorities
• - physician fee schedules
• - drug formularies

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Background (continued)

• We propose that the determination of the Medicare
  Basket in Canada requires a dialogue about the
  definition of equity and its relationship to the
  efficiency, effectiveness and overall
  sustainability of the publicly funded health
  system

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Background (continued)

• This dialogue should be informed by
• (1) a review of current approaches taken to
  define a basket of services across a number of
  jurisdictions
• (2) an analysis of the values underlying current
  health care allocation decisions with respect to
  the basket
• (3) a framework which can guide the process of
  conducting dialogue with key stakeholders

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Purpose and Objectives

• The PURPOSE of this program of research is to
  produce a framework and process for public
  dialogue about the definition of the Medicare
  basket in Canada
• The OBJECTIVES are
• 1. To develop a preliminary framework which
  will guide data collection and analysis
  regarding the different approaches to
  collective funding of health services across
  jurisdictions

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Objectives (continued)

• 2. To investigate the approaches to defining
  the basket of services to be covered across
  Canada, European countries and the private
  health sector using this framework
• 3. To clarify the ethical implications of the
  identified approaches

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Objectives (continued)

• 4. To incorporate the findings into a revised
  framework and design a strategy for conducting
  dialogue using the framework as a guide
• 5. To test the acceptability of both the
  framework and the process for conducting
  dialogue with key decision makers and community
  representatives in Ontario and the Atlantic
  Provinces

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Methods

• This program of research will consist of 3
  inter-related and inter-connected stages
• Stage 1 Developing the framework
• Stage 2 Refining the framework
• Stage 3 Testing the framework

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Methods1. DEVELOPING the Framework

• A preliminary framework to guide data collection
  will be developed based on Deborah Stones work
  on equity and Raisa Debers work on the Four
  Screen Model
• Stone proposes that a discussion of equity
  requires consideration of 8 separate elements
  which can be grouped into 3 general categories
  recipients, items and process

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Methods1. DEVELOPING the Framework

• Issues relating to defining recipients
• Appropriateness and acceptability of the current
  definition of recipients under the CHA

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Methods1. DEVELOPING the Framework

• Issues relating to defining items
• Deber Four Screen Model
• Pre-screen Is the service ethically acceptable?
• If the answer is no then item is out
• Screen 1 Is it effective (does it work)?
• requires expert input

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Methods1. DEVELOPING the Framework

• Screen 2 Is it appropriate (how much will
  it benefit potential recipients)?
• often a decision made by front line
  providers
• Screen 3 Does the recipient really want the
  service, given the risks and benefits?
• requires dialogue between potential patient
  and provider

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Methods1. DEVELOPING the Framework

• Screen 4 Should the public pay for it?
• Are we as a society willing to let people
  priced out of the market for this service?
• NOTE The Four Screen Model does not deal
  with issues of process or with the ethical
  implications of various approaches

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Methods1. DEVELOPING the Framework

• c) Issues related to defining process
• Equity includes not only the end result but a
  sense of fair process by which the results were
  achieved
• Fairness of the process also includes
  consideration of who gets to make the decisions
• This preliminary framework will guide the
  development of a common template for data
  collection and analysis for 3 of the 4 projects
  in Stage 1

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Methods1. DEVELOPING the Framework

• Project 1 Canadian Models
• Deber, Neville, Nauenberg Thompson
• 3 categories of resource allocation decisions
• Decisions about which service categories will be
  given public financing
• Decisions about how resources will be allocated
  within a service category required by the CHA
• Decisions about how resources will be included
  within a service category where that service is
  not required under the CHA

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Methods1. DEVELOPING the Framework

• Project 1 Canadian Models
• Methods include (1) a preliminary questionnaire
  followed by semi-structured interviews with
  decision makers and
• (2) document review

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Methods1. DEVELOPING the Framework

• Project 2 European Models
• Rathwell, in consultation with the European
  Healthcare Management Association and the
  European Observatory on Health Care Systems
• Critical review of the published and grey
  literature
• Key informant interviews with individuals with
  direct experience of involvement in defining a
  core package of publicly funded health services

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Methods1. DEVELOPING the Framework

• Project 3 European and North American
  Private Sector Models
• Larry Nestman, in consultation with the WHO
  Observatory, will examine
• - the impact that tax incentives have on
  devising packages of health services
• - payment systems ( co-payment, full payment)
  as they relate to service access and coverage
• - various types of baskets and processes
  utilized to shape the baskets, such as listing
  and de-listing

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Methods1. DEVELOPING the Framework

• Project 4 Ethical Implications of Decision
  Frameworks and Processes
• Nuala Kenny, in consultation with the team
• Development of an analytical framework
  incorporating ethical models and approaches
• Focus will be to make transparent the both the
  values underlying the decision making processes
  and how they relate to the decision making
  structures examined in the first 3 projects

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Methods1. DEVELOPING the Framework

• Project 4 Ethical Implications of Decision
  Frameworks and Processes
• Assessment of the ways in which formal ethical
  analysis might contribute to health policy
  development
• Analysis of interpretation of values and review
  of the importance of values in the Canadian
  health reform discourse
• Analysis of methods generally utilized in making
  acceptable ethical decisions about the limiting
  of health care services to determine what has
  worked or not worked

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Methods2. REFINING the Framework

• Neville, Deber, Conrad, Thompson, Ward and
  Nurenberg
• Consolidate results from the 4 projects in Stage
  1 and refine the preliminary dialogue framework

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Methods2. REFINING the Framework

• Present the refined framework to decision making
  partners and advisory committee members to
• (a) elicit feedback on the framework and
• (b) identify a process for using the
  framework to conduct a dialogue with decision
  makers and representatives of the public
  interest
• Methods include workshop presentations, in-
  person and telephone interviews

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Methods3. TESTING the Framework

• Rathwell, Deber, Neville,
• Develop an instrument which can be used as a
  guided survey to test the acceptability of our
  framework with representatives of the public
  interest in 5 provinces (Community Health Boards
  in Atlantic Canada and District Health Councils
  in Ontario)
• Determine the extent to which there is agreement
  with the content of the proposed framework and
  the most appropriate process for conducting a
  dialogue

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Project Deliverables

• A synthesis of current practices with respect to
  making basket decisions within Canada and other
  jurisdictions
• An analysis and clarification of the values
  demonstrated in current basket decision-making
  processes and outcomes
• A framework and recommended process for
  conducting dialogue about the medicare basket

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Knowledge Transfer Strategies

• Project is extremely consultative and a key
  design element throughout involves obtaining
  feedback on various iterations of the framework
• Workshops, face-to-face meetings
• Policy synthesis paper, quarterly
  communiqués/newsletters
• Fact sheets about lessons learned
• Presentations at national and local conferences
• Web site and listserve postings
• Media releases

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Project Timelines

• Stage 1 Developing the Framework
• March 03 June 04
• Stage 2 Refining the Framework
• January 04 December 04
• Stage 3 Testing the Framework
• January 05 March 06

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Thank You To Our Research Funders

• Canadian Health Services Research Foundation
• Nova Scotia Health Research Foundation
• Newfoundland and Labrador Centre for Applied
  Health Research
• Ontario Ministry of Health and Long Term Care

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Thank You To Our Advisory Committee Members

• Jim Marshall, United Church of Canada
• Scott Dudgeon, Metro Toronto District Health
  Council
• Gilbert Sharpe, former head, legal division,
  Ontario MHLTC,
• John Peddle, CEO, NLHBA
• Elizabeth Davis, former CEO, HCCSJ

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Thank You To Our Advisory Committee Members

• Robert Cook, NS Association of Health
  Organizations
• Rick Nurse, former CEO, IWK, Halifax
• Paul Kovacs, Insurance Bureau of Canada
• Owen Adams, Canadian Medical Association
• Glen Brimacombe, Conference Board of Canada
• Canadian Nurses Association