Priority setting in Ontario's LHINs:
Ethics & economics in action
Jennifer Gibson, PhD
University of Toronto Joint Centre for Bioethics
Craig Mitton, PhD
School 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 ethics 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?
Priority Setting Approaches
ECONOMICS
Program budgeting &
marginal analysis
(PBMA)
ETHICS
Accountability for
reasonableness (A4R)
PUBLICITY
1
2
3
4
5
FAIR
PROCESSES
RELEVANCE
1
REVISION
EMPOWERMENT*
5 2
OPTIMAL BENEFITS
*Gibson, Martin & Singer. SSM 2005; 61:
2355–2362.
ENFORCEMENT
Interdisciplinary Approach
PUBLICITY
RELEVANCE
REVISION
1
2
3
4
5
1
EMPOWERMENT
5 2
ENFORCEMENT
Gibson, Mitton, et al., JHSRP 2006;
11(1): 32-37.
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
PHASE I
PHASE II
PHASE III
PHASE IV
Development
Implementation
• LHIN Pilots (3)
Evaluation
Refinement
Oct ’07…
Feb ’08…
Nov ’08…
Feb-Mar ‘09
Phase I. Development
1a. Criteria: Link decisions explicitly to
local/system strategic plans, population needs,
system values, & performance goals
STRATEGIC FIT
LHIN and MOH strategic plans; Provider system role (mandate & capacity)
POPULATION HEALTH
Health status, prevalence, health promotion/ prevention
SYSTEM VALUES
Client-focus, partnerships, community engagement, innovation, equity, operational
efficiency
SYSTEM PERFORMANCE
Access, quality, sustainability, integration
1b. Criteria-based Decision Tool: Rate/rank
funding options systematically to ensure
consistent rationale across decisions
Step 1. Compliance Screen
 Legal/regulatory
 Contractual Agreements (e.g., AAs)
1
2
3
4
5
1
2
3
4
5
Step 2. Evaluation (15 criteria)
Step 3. Cost-Benefit Analysis
Step 4. System Readiness Screen
1
1 3
5 2
 LHIN capacity
 Interdependency
 Risk
 Health system impact
2. Processes: Establish overall legitimacy and
fairness of decisions, including constructive
stakeholder involvement
4. Develop decision criteria
with stakeholder input.
3. Clarify existing
resource mix.
5. Identify & rank funding
options.
1
2
3
4
5
2. Identify priority setting
committee.
1
1. Determine aim & scope
of decision making.
1 3
6. Communicate decision
& rationale.
1
2
3
4
5
5 2
7. Provide formal decision
review process.
8. Evaluate & improve.
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?