Priority setting in Ontario's LHINs: Ethics & economics in action Jennifer Gibson, PhD...

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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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

jennifer.gibson@utoronto.ca

craig.mitton@ubc.ca

Questions?Comments?