priority setting in ontario's lhins: ethics & economics in action jennifer gibson, phd...
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Priority setting in Ontario's LHINs:
Ethics & economics in action Jennifer Gibson, PhD
University of Toronto Joint Centre for Bioethics
Craig Mitton, PhDSchool of Population & Public Health,
University of British Columbia
On behalf of the LHIN Priority Setting Working Group
Session Goal & Objectives
Goal: To share experience with developing a priority setting framework for Ontario’s Local Health Integration Networks (LHINs)
Objectives:- To introduce an interdisciplinary priority setting
framework based on ethical and economic principles
- To describe its implementation & evaluation in Ontario’s LHINs
- To identify key lessons learned
Guiding Principles
Economic principles of ‘value for money’- What priorities should be set to optimize
health benefits & achieve health system goals in resource constraints?
Ethical principles of fair process- How should these priorities be set to ensure
legitimacy and fairness in the eyes of affected stakeholders?
*Gibson, Martin & Singer. SSM 2005; 61: 2355–2362.
Priority Setting Approaches
ECONOMICSProgram budgeting &
marginal analysis (PBMA)
ETHICSAccountability for
reasonableness (A4R)
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REVISION
RELEVANCE
PUBLICITY
EMPOWERMENT*
ENFORCEMENT
FAIRFAIR
PROCESSESPROCESSES
OPTIMAL BENEFITSOPTIMAL BENEFITS
Gibson, Mitton, et al., JHSRP 2006; 11(1): 32-37.
Interdisciplinary Approach
REVISION
RELEVANCE
PUBLICITY
EMPOWERMENT
ENFORCEMENT
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LHIN Priority Setting Project
Background: Ontario’s LHINs
Launched in 2005
No direct service provision - responsible for planning, coordinating, & funding services
Gradual devolution of accountability from ministry to LHINs (early 2007)
Project Goal
To develop a priority setting framework that would help LHINs:
− Align resources strategically with system goals and population needs
− Facilitate constructive stakeholder engagement
− Make publicly defensible decisions based on available evidence and community values
− Demonstrate public accountability for finite health resources
Project Overview
Feb-Mar ‘09Nov ’08…Feb ’08…Oct ’07…
PHASE IVPHASE IIIPHASE IIPHASE I
Development
Implementation• LHIN Pilots (3)
Refinement
Evaluation
Phase I. Development
1a. Criteria: Link decisions explicitly to local/system strategic plans, population needs, system values, & performance goals
STRATEGIC FITLHIN and MOH strategic plans; Provider system role (mandate & capacity)
POPULATION HEALTHHealth status, prevalence, health promotion/ prevention
SYSTEM VALUESClient-focus, partnerships, community engagement, innovation, equity, operational efficiency
SYSTEM PERFORMANCEAccess, quality, sustainability, integration
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Step 1. Compliance Screen Legal/regulatory Contractual Agreements (e.g., AAs)
Step 2. Evaluation (15 criteria)
Step 3. Cost-Benefit Analysis
Step 4. System Readiness Screen LHIN capacity Interdependency Risk Health system impact
1b. Criteria-based Decision Tool: Rate/rank funding options systematically to ensure consistent rationale across decisions
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1. Determine aim & scopeof decision making.
4. Develop decision criteriawith stakeholder input.
3. Clarify existing resource mix.
5. Identify & rank funding options.
7. Provide formal decision review process.
8. Evaluate & improve.
2. Identify priority settingcommittee.
6. Communicate decision& rationale.2
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1. Determine aim & scopeof decision making.
4. Develop decision criteriawith stakeholder input.
3. Clarify existing resource mix.
5. Identify & rank funding options.
7. Provide formal decision review process.
8. Evaluate & improve.
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5 54321
1 35 21
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1 35 21
1. Determine aim & scopeof decision making.
4. Develop decision criteriawith stakeholder input.
3. Clarify existing resource mix.
5. Identify & rank funding options.
7. Provide formal decision review process.
8. Evaluate & improve.
2. Identify priority settingcommittee.
6. Communicate decision& rationale.
2. Processes: Establish overall legitimacy and fairness of decisions, including constructive stakeholder involvement
Gibson, et al., Healthcare Quarterly 2005, 8(2);Mitton & Donaldson, The Priority Setting Toolkit, BMJ Books, 2004.
Phase II. Implementation
Framework piloted in 3 LHINs
Funds available for strategic investment: $800K - $2M
Success rate: ~10%
Phase III: Evaluation
On-line Survey of health service providers (n = 110)
Interviews with LHIN Staff (~30) across all three pilot sites
Analysis:- Descriptive analysis - survey data (closed)- Thematic analysis - interviews and survey data
(open-ended)- Evaluation - A4R as a conceptual framework
Key Lessons Learned
Key Findings
Overall, framework perceived to be helpful.
Value of framework Systematic & disciplined approach Greater consistency and less subjectivity in DM Credible basis for explaining decisions Basis for constructive dialogue about scarcity internally and externally Good preparation for ‘high stakes’ re-allocation (trust-building)
Key Findings
Contextual realities present challenges for implementation
Challenges Changing ministry directions Tight timelines Inconsistent availability of data “Promise of benefit” vs. real benefit – need for performance monitoring Uneven playing field due to different capacities of provider organizations (small vs. large)
What counts as fair?
Funding success Unfunded – somewhat more likely to think
process was not fair (35% vs. 21%)
What counts as fair?
Transparency, transparency, transparency
FAIR NOT FAIR
LHIN’s goals, criteria, & funding processes were communicated clearly.
85%Agreed
60% Disagreed
LHIN’s funding rationales were communicated clearly.
52%Agreed
89%Disagreed
Concluding comments Trust is more not less important during a
time of system transformation and change.
Incremental implementation and open evaluation may be key tools to advance trust within the system.
Interdisciplinary project is unfinished -time to engage organizational change theory.
Priority setting in Ontario's LHINs:
Ethics & economics in action
Questions?Comments?