Lecture 4 - Priority setting

Question 1

Why do we need priority setting?

Answer 1

1. Resources are scarce
2. Demand is infinite
3. Need transparency and accountability in resource allocation decisions

Question 2

What are the 4 types of priority-setting approaches?

Answer 2

1. Demand-based
2. Need-based
3. Exclusion (cost-benefit)
4. Clinical outcomes

Question 3

What are demand-based priority-setting approaches? Detail the focus, pros and cons

Answer 3

Focus: prioritizes information based on public demand or patient preferences e.g. surveys, focus groups, town hall meetings

Pros: ensures interventions address the needs of the public, potentially increasing utilisation

Cons: may neglect useful but unpopular interventions (e.g. for rare diseases), public demand may not reflect the long-term health needs of the population or be cost-effective

Question 4

What are need-based priority-setting approaches? Detail the focus, pros and cons

Answer 4

Focus: prioritises interventions based on the burden of disease within a population e.g. prevalence, mortality, disability

Pros: targets intervention towards the most significant health impact which should theoretically maximise population health benefit

Cons: may neglect less prevalent diseases, doesn’t necessarily consider cost-benefit or public opinion

Question 5

What are clinical guideline-based priority-setting approaches? Detail the focus, pros and cons

Answer 5

Focus: Relies on evidence-based clinical guidelines which detail scientific evidence and best practices

Pros: Promotes evidence-based decision-making and ensures interventions are clinically sound

Cons: Might not consider cost-effectiveness or populations’ specific needs. May not address emerging needs until guidelines are updated.

Question 6

What are exclusion-based priority-setting approaches? Detail the focus, pros and cons

Answer 6

Focus: exclude services which are of low value (in other words, not cost-effective)

Pros: prioritise services with highest return, efficient use of resources, promote services with highest impact on population health

Cons: difficult to determine cost-effectiveness, data may be incomplete, doesn’t consider the broader societal benefit, may favour diseases that impact a large population

Question 7

Give a real-world example of demand-based prioritisation

Answer 7

In the 19th Century there was public outcry over unsanitary conditions in London during the Industrial Revolution. This led to government investments in sanitation infrastructure such as sewage systems and clean water supplies.

Question 8

Give a real-world example of needs-based prioritisation

Answer 8

During the COVID-19 pandemic, infection rates were increasing rapidly, leading governments to prioritise the development and dissemination of COVID vaccinations

Question 9

Give a real-world example of exclusion/cost-effectiveness prioritisation approaches.

Answer 9

Oregon Medicaid

• Goal of the program was to extend coverage to all Oregonians below 100% of the federal poverty level (as opposed to 58% FPL, as it was previously) by limiting coverage to a basic bundle of services decided by the Medicaid budget and a cost-effectiveness ranking of available medical services
  o The Oregon Health Services Commission (OHSC) used public hearings to include public opinion in the ranking of medical services.
• This initial method was, however, abandoned because of public outcry over the resulting ranking of services.
• The Commission pivoted to relying more on expert knowledge and intuitive judgements about the appropriateness of medical services.
• The rationing of Medicaid services was successful in some respects since it extended coverage to a wider population but it was extremely controversial, with some arguing that the program reduced access to certain treatments for low-income individuals and that whether someone gets treatment or not should not be based on a dollar value.

Question 10

Give a real-world example of clinical guideline-based prioritisation

Answer 10

UK National Institute for Health and Care Excellence (NICE)

1. Appraise health technologies
2. Develop clinical guidelines
3. Assess interventional procedures

Won’t spend over £30,000 per QALY gained

Question 11

What are the 5 rationing principles? Explain them

Answer 11

1. Lottery principle: relies on chance to determine who receives care
2. Rule of rescue: prioritise people who are facing immediate death
3. Health maximisation: maximise the overall health of the population
4. Fair innings: fairness based on the amount of life already lived (everyone gets the normal span of lives lived, so prioritise youth)
5. Equalising opportunity for health: create equal opportunities for everyone to achieve good health (everyone responds to treatments differently)

Question 12

What are the 5 priority setting techniques?

Answer 12

1. Individual variables
2. Priority matrix
3. Economic evaluation
4. Group consensus techniques
5. Public consultation methods

Question 13

How do you use individual variables in priority setting? What are the pros and cons?

Answer 13

Care is prioritised based on factors related to the patient or treatment.

For example, patients with life-threatening illnesses are prioritised over others (rule of rescue principle) or patients with a better chance of recovery from a treatment are prioritised over those with a worse prognosis (health maximisation principle) or younger people should get treatment instead of older people (fair innings principle).

While using individual variables may seem straight forward, the principles which drive priority decisions can lead to very different outcomes.

Question 14

How do you use a priority matrix in priority setting? What are the pros and cons?

Answer 14

Priority criteria are plotted on axes and treatment options are plotted based on their score on each criterion.

Being visual, this method may be easier for decision-makers to interpret, however results are highly contingent on which priority criteria are used.

Choosing the weighting of each criteria can be subjective which means different matrices can lead to different rankings.

Question 15

How do you use economic evaluation in priority setting? What are the pros and cons?

Answer 15

Allows for comparisons across broad sets of interventions by combining different outcomes of interest into a single measure.

A common economic measure is cost per disability-adjusted life years (DALYs) or cost per quality-adjusted life years (QALYs). In other words, the cost associated with reducing the years lost and living with disability, or the cost to increase years lived in good health.

One disadvantage to these methods is they focus on the average health of a population and, therefore, do not reflect the unique needs of each population within the sample.

They can also potentially discriminate against the old or disabled and may undervalue some aspects of health, such as mental health.

Question 16

Why should the general public be engaged in making policy decisions?

Answer 16

• It bring legitimacy to the policy process
• Makes the process more transparency and accountable to the public
• Provides feedback for policy makers
• Generates a culture of debate
• Make bureaucratic processes democratic

Question 17

Explain how Norway used a clinical, evidence-based approach to policy reforms.

Answer 17

• 1st country to set up National Priority Commission (1985) which had politicians, health experts and the public. Used to prioritise what services would be included in the public system.
• Priority levels
  o Level 1: basic health services
  o Level 2: additional health services
  o Level 3: low priority or borderline services
  o Level 4: no priority and outside priority system
• Goal was to have greatest number of health life years for all, which are fairly distributed
• Criteria - the priority of an intervention increases:
  o The health-benefit criterion: with the expected health benefit from the intervention
  o The resource criterion: the less resources it requires
  o The health-loss criterion: with the expected life time health loss of the beneficiary in the absence of such an intervention

Question 18

Give a real-world example of dilemmas with rationing/priority setting in healthcare (hint - in UK)

Answer 18

• Jaymee Bowen was diagnosed with a form of cancer (non-Hodgkin’s lymphoma) at a young age (around 6 years old) in the early 1990s.
• After initial treatment, her cancer returned (acute myeloid leukemia).
• Doctors presented various treatment options, some considered aggressive and experimental.
• Conflict
  o Jaymee’s father, David Bowen, wanted his daughter to receive all available treatments, regardless of cost or the experimental nature of some options.
  o The Health Authority, responsible for funding her care, had budgetary constraints and concerns about the cost-effectiveness of some proposed treatments.
• Issues
  o Rationing in the NHS: The case highlighted the challenges of resource allocation in the NHS, where healthcare is free at the point of access but resources are finite.
  o Uncertainty in Medical Treatment: The case exemplified the complexity of decision-making when dealing with aggressive or experimental treatments with limited

Question 19

What are the 3 trends in priority setting

Answer 19

1. Rely more on clinical guidelines instead of exclusion of services
2. More emphasis on improving processes instead of creating technical fixes
3. Changing methods for priority setting (e.g. understanding the limitations of QALYs)

Question 20

Explain, using numbers, the 4 insensitivities related to QALYs.

Answer 20

1. Insensitivity to age; values a young person gaining 10 years of life the same as a pensioner gaining 10 years of life
2. Insensititivity to severity; intervention that improves the quality of life of one severely ill patient from 0.1 to 0.2 for 4 years is valued the same as an intervention that improves the quality of life of a generally healthy patient from 0.8 to 0.9 for 4 years
3. Insensitivity to distribution of benefits; an intervention that improves the life of one person by 1 QALY is the same as an intervention that improves the life of 100 individuals by 0.01 QALYs (negligible)
4. Insensitivity to culpability; intervention that improves the quality of life in smoking-related disease by 0.1 is valued the same as an intervention that improves the quality of life of someone with a congenital disease by 0.1
5. Favours those with more treatable conditions and those with a greater potential for health
6. Patient surveys are highly sensitive to the way questions are asked
7. Might not be ideal for comparisons across populations (different perspectives of health and well-being)
8. May not account for all aspects of health (e.g. undervalue mental health)