1. Methods in priority setting
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2. The goal in resource allocation
decisions
Decision-makers need to determine:
what health care services to provide
for whom to provide services
how to provide services
where services should be provided
… in order to meet local and/ or system level
objectives including access, health gain…
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3. How is that typically done?
Resource allocation decisions are typically based on:
Historical patterns with incremental adjustment
Politics and the ‘squeaky wheel’
Needs assessment
Core services
economic evaluation (limited)
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4. What is required?
A pragmatic decision-making approach that….
– Aligns resources strategically with system goals and
community needs
– Leads to publicly defensible decisions based on available
evidence and community values
– Facilitates stakeholder engagement around improving benefit
with limited resources
– Supports the public accountability of health care decision-
makers
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5. This leads us in the direction of Program Budgeting
and Marginal Analysis (PBMA)
Formal framework to assist decision-makers in
making resource allocations decisions
Combines medicine, economics and ethics
Used since the 1970’s in health care
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6. Basic thinking behind PBMA
1. What resources are available in total?
2. In what ways are these resources currently spent?
3. What are the main candidates for more resources and
what would be their effectiveness?
4. Are there any areas of care which could be provided to the
same level of effectiveness but with less resources, so
releasing resources to fund candidates in (3)?
5. Are there areas of care which, despite being effective,
should have less resources because a proposal in (3) is
more effective (per $ spent)?
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7. PBMA: Practical Steps
Determine aim and scope of activity
Identify and map resource use
Form an advisory panel
Define and weight decision making criteria
Identify options for service growth and resource release
Evaluate proposed investments and disinvestment
Validate results, recommendations for (re)-allocation,
communicate decisions
Evaluation, refinement and ongoing revision
Peacock et al. 2006
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8. Determine aim and scope
of activity
Is the aim to bridge a deficit situation, to
allocate new funding, to consider possible re-
allocations of existing funding…
What parts of the organization are included in
the process implementation?
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9. Mapping resource use
Objective is to have an accurate summary of
information about services provided across the
continuum of care
- Costs and benefits
 May not have a clear picture of how many services
are provided and by whom
 Splitting costs in different ways
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10. The Advisory Panel
Multi-disciplinary mix of stakeholders
Decision-makers, policy-makers, clinician leaders
Finance/information personnel
Consumer/community representatives
Key responsibilities are:
-Establishing assessment criteria (process to do this
critical for buy-in)
- Identify and assess service growth and resource
release options
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11. Benefit measurement
Multi-attribute decision analysis (MCDA)
Limited ‘real’ health care examples published
Reflects multiple objectives
Score service options for investment and
disinvestment in terms of benefits for patients
against pre-defined set of criteria
To get a single measure of each service’s benefit
need to combine the scores
Mitton and Donaldson 2004
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12. Assessment Criteria
Basis for priority setting decisions
Should be specified at outset of process in explicit
manner
Operational enough to assess services against
Should not overlap (mutually exclusive)
Need to clearly define
Embody organizational values
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13. Use of ‘evidence’
Stakeholder Input
Rating options against
The Community
pre-defined criteria Staff / Doctors
Board
Population Business Plan
Needs Priorities
Determining
Operational Priorities:
Identifying Margins
Provincial for Change Practice
Requirements / Guidelines &
Targets Standards
Service Utilization
Output / Outcomes Data Financial Data
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14. Validation
Prior to final decisions, recommendations should be
taken to various stakeholders
More than ‘face validity’ feedback
Don’t go unless willing to re-assess
Seek stakeholder feedback on recommendations
using a formal decision review process
New data/information; errors
Failure of due process
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15. Physician roles
Advocacy vs. system perspective
Critical appraisal of competing evidence from a
range of sources and settings
Assessment of clinical evidence from systematic
reviews
Expert judgment when ‘good evidence’ lacking
Ruta et al. 2005
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16. Board roles
Endorsement and support of the process
Policy approval – direction and monitoring
Assure alignment with organizational priorities
Explicit fiscal framework
Involved and engaged stakeholders
Buy in for investment and disinvestment
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17. Public role
Only go there if really want input!
Values in relation health care objectives
Possible input on assessment criteria
Possible participation on advisory panels
Focus groups to provide viewpoint on clinical areas
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18. Expected Outcomes
Primary benefit of PBMA
• Achieving real resource shifts that are consistent with
strategic decision-making objectives
Secondary benefits of PBMA
• Ownership of planning process
• Evidence driven decisions
• Transparent and defensible decision making
• Clinician engagement and partnership
Gibson et al. JHSRP 2006
Ruta et al. BMJ 2005
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19. Lessons from experience-key
success factors
Shared vision
Stakeholder buy-in
Transparency
Credible commitment
Resources for process (training, ongoing support, time freed up)
Incentives to encourage participation
Follow-through (execution)
Facilitating change process
Learning/ quality improvement
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20. Canadian examples
Chinook Health Region (Alberta) Home and community care
Surgery, chronic disease Menno Home and Hospital (BC)
Headwaters Health Authority (Alberta) Seniors’ care
Surgery, long term care BC Cancer Agency (BC)
Calgary Health Region (Alberta) Screening, select drug therapies
Macro, children’s services St. Joseph’s Health Centre (Toronto)
Vancouver Island Health Authority (BC) All clinical service areas
Macro, within portfolios North West, Central West and Champlain
LHINs
Interior Health Authority (BC)
Urgent priorities, Aging at Home,
Community care services Alternative levels of care
Northern Health Authority (BC)
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21. Summary
Health care environment is politically charged and
complex
Need a pragmatic framework that can introduce
evidence based decision making
PBMA is one way to take on an explicit approach to
priority setting
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22. What’s in a name?
Point is not ‘PBMA’ or ‘no PBMA’. It is about:
Use of explicit criteria (e.g., MCDA)
Fit within a broader process of decision making
 Priority setting committee
 Evidence based
 Transparent
 Appeals mechanism
Ownership of recommendations
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