Eric Nauenberg, Ph.D.*

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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

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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 decision-making body.

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Disclaimer 2

• The content herein may sic shed some light on
  why the foot is connected to the head when it
  comes to decision-making, but the explanation is
  likely to be incomplete.
• Source Nauenberg E., The Health Economists
  Approach to Anatomy. Forthcoming, 2010.

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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

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Outline

• Conceptual Framework
• Simple Model of Health Care Exclusion Whats in
  and whats out of the Medicare basket?
• Jurisdictional Levels Processes Used in
  Canadian Health Care Decision-Making
• Conclusion

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Conceptual Framework

• Deconstruct health care decision-making
• Define health care decision-making as opposed to
  health care advisory-making

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Health Care ExclusionWhats In and Whats 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).

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Health Care ExclusionWhats In and Whats 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.

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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.

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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.

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Advisory Example OHTAC Process for Reviewing
Health Technologies
HT evidence based policy analysis and Ontario
based data analysis 16 weeks
Pre-assessment for OHTAC prioritisation

• Recommend
• Implement
• Not implement
• Re-visit
• Field evaluation
• Registry study

Application to OHTAC through MAS for review
MOHLTC response and policy decision within 60
days. Appeals process
Application with Sponsorship
MAS
OHTAC
MOHLTC
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Medical Advisory Secretariat HTPA Process

• Systematic Review - Effectiveness
• Search databases
• Selection criteria
• Analysis
• Consult experts,
• industry

• OHTAC Critical Review
• Recommend to DM
• Disseminate on Website

• Policy Options Ontario Specific Analysis
• Ethical, legal, regulatory, systems
  implications
• Options

• Prioritisation
• Description
• Priority score
• OHTAC
• Prioritisation

• Economic Analysis
• Budget impact
• CEA
• Cost avoidance
• Expert Review of HTPA

-

• Published systematic review available

MAS HTPA Unit
Synthesis Review
MAS HTPA
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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.

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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.

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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

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Components of the Decision-Making Process
Centralized
Devolved
Level of Decision-Making
Macro
Meso
Micro
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Three Broad Sets of Health CareDecision-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.

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Taxonomy for Health Care Decision-Making
Decision-making process
Centralized
Devolved
Level of Decision-making
Macro
Meso
Micro
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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).

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Provincial Role

• Provinces effectively define services that will
  be publicly-funded, 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)

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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.

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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.
• Quebecs 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-of-province/out-of-country treatment

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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.
  (Hands-off/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.

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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.

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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)

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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.

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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 decision-making 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

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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