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Are Publicly Financed Dental Care Programs in Ontario

Delivering the “Best Bang for their Buck?”

E. Cardoso, V. Pilly, C. Quiñonez

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Outline• Current situation• Strategies abroad• Conceptual framework • Multi-Criteria Decision Analysis (MCDA) tool• Strengths & Weaknesses• Conclusion

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Current situation• Imbalance between financial

resources and challenges– Increasing demand–Higher costs–Ethical dilemmas (Xie et al., 2011)

• Sustainability of dental care programs • Recent call to increase access

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Current situation

• Challenge = Opportunity– Chase the “best bang for their buck”– Enhance process effectiveness & health outcomes

• Mantra of “no new dollars”– Scrutinize the basket of dental care services– Resource allocation optimization (Elshaug et al., 2009)

– Evidence and best practices

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Strategies abroad

Identify interventions with questionable outcomes (Garner & Littlejohns , 2011)Identify unsafe or ineffective services

(Elshaug et al., 2012)

Ethical principles for resource allocation(WHO,2004)

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Conceptual framework

• Decision support tool– Multi-Criteria Decision Analysis (MCDA)– Health Technology Assessment (HTA)

• Evaluate existing or future practices • Evaluation phase or planning phase • Help decision action toward program

objectives

Yes

No

Yes

No

No

Yes

No

Procedure

Program Objectives Analysis

Are program objectives

met?

Do not fund

Analysis against need

Is procedure needed?

Analysis against effectiveness

Is procedure effective?

Analysis against appropriateness

Is procedureappropriate?

Is it the only option?

Fund

Yes

Yes

Is it cost effective?

Cost-effective analysis

Yes No

Analysis deferred?

NoNo

YesProfessionalor Patient

preference?

Procedure analysis

YesNo

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Building the proposed MCDA

• Various criteria listed and arranged in a hierarchical, priority-setting manner

• Dental procedure must satisfy all listed decision criteria to be funded– Fails to meet criterion definition flagged not

to be funded– Lacks evidence considered for evidence-

based review

Yes

No

Yes

No

No

Yes

No

Procedure

Program Objectives Analysis

Are program objectives met?

Analysis against need

Is procedure needed?

Analysis against effectiveness

Is procedure effective?

Analysis against appropriateness

Is procedureappropriate?

Yes

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Program Objective Analysis• Procedure should:– Reflect on the founding principles of

the program – Support the ultimate goals or

programs objectives– Preserve the sustainability of the

program

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Need Analysis

• Instrumental aspect of “need”• Not linked to ill health• “Minimum amount of resources required

to exhaust capacity to benefit” (Culyer and Wagstaff, 1993)

• Some needs ought to go unmet to be equitable (Culyer , 1998)

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Effectiveness Analysis• Achieved its outcome in real life setting

(Guindo, 2012)

• Strength of evidence for evidenced-based decision (Schanschieff , 1986)

• How much improvement after the procedure is provided (Lavis, 1996)

• Basis for ‘Approppriateness’ (Lavis, 1996)

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Appropriateness Analysis • Effective for a particular patient or

population• No efforts are made to balance benefits

and costs yet (Lavis, 1996)

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Cost-effectiveness Analysis

• Identify worth financing services from other options (Johnson et al., 2009)

• Simplest criterion• Last in the hierarchy (Musgrove, 1999)

• Other options for public funding (Musgrove, 1999)

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Professional / patient preferences Analysis

• Further analysis to avoid resource overutilization

• Individual welfare is not for the scope of social responsibility (Wikler, 2002)

Yes

No

Yes

No

No

Yes

No

Procedure

Program Objectives Analysis

Are program objectives met?

Analysis against need

Is procedure needed?

Analysis against effectiveness

Is procedure effective?

Analysis against appropriateness

Is procedureappropriate?

Yes

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Yes

Do not fund

Fund

YesCost

effective ?

Cost-effective analysis

Yes No

Analysis deferred?

No

No

YesProfessional or Patient

preference?Procedure

analysis

Yes

No

Only option ?

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Strengths

• Systematic and evidence-informed tool• Rational and transparent decision-making

process• Identifies intrinsic values of each procedure• Drives program performance according to

issues of sustainability

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Weaknesses

• Resistance from service providers • Resistance from funders• Centralized administration

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Conclusion• Inequality in access to dental care as a public

health issue• Sustainability of dental public health programs• Maximize health benefits as an ethical objective of

the health care system • Proposed systematic tool

– Evaluate current public oral health programs against their strategic goals

– Push towards a stronger policy which includes vulnerable populations other than children

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Thank You!

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References• Culyer AJ. The morality of efficiency in health care — some

uncomfortable implications. Health Econ 1992; 1: 7-18.• Culyer, A. Need-is a consensus possible? J. Med. Ethics 24, 77-80

(1998)• Elshaug, A., Moss, J.R., Littlejohns, P., Karnon, J., Merlin, T.L.& Hiller,

J.E. (2009) Identifying existing health care services that do not provide value for money. MJA 190, 5: 269-73.

• Elshaug, A. G., Watt, A. M., Mundy, L. & Willis, C. D. Over 150 potentially low-value health care practices: an Australian study. Med. J. Aust. 197, 556-560 (2012)

• Garner, S. & Littlejohns, P. Disinvestment from low value clinical interventions: NICEly done? BMJ 343, d4519 (2011)

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References• Guindo, L. A. et al. From efficacy to equity: Literature review of decision criteria for

resource allocation and healthcare decisionmaking. Cost. Eff. Resour. Alloc 10, 9-7547-10-9 (2012)

• Johnson, A. P. et al. Health technology assessment: a comprehensive framework for evidence-based recommendations in Ontario. Int. J. Technol. Assess. Health Care 25, 141-150 (2009)

• Lavis, J. N. & Anderson, G. M. Appropriateness in health care delivery: definitions, measurement and policy implications. CMAJ 154, 321-328 (1996)

• Musgrove, P. Public spending on health care: how are different criteria related? Health

Policy 47, 207-223 (1999) • Ontario Association of Public Health Dentistry (2005) Preparing for change, Retreat April 27 - 29, 2005.

Barrie: Vision Management Services, Ontario Association of Public Health Dentistry.

• Quiñonez C, Sherret L, Grootendorst P, Shim MS, Azarpazhooh A, Locker D. An environmental scan of provincial/territorial dental public health programs. Office of the Chief Dental Officer, Health Canada. (2007) http://www.fptdwg.ca/English/e- environmental.html

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References• Schanschieff S. Report of the committee of enquiry into unnecessary

dental treatment, H M Stationery Office, Great Britain Department of Health and Social Security, England, 1986

• Wikler, D. Personal and social responsibility for health. Ethics Int. Aff. 16, 47-55 (2002)

• World Health Organization (2004): Guidance on ethics and equitable access to HIV treatment and care. http://www.who.int/ethics/Guidance%20on%20Ethics% 20and%20HIV.pdf.

• Xie, F. et al. Using health technology assessment to support evidence-based decision-making in Canada: an academic perspective. Expert

Rev. Pharmacoecon Outcomes Res. 11, 513-521 (2011).