Building a Public Dialogue Framework for Defining the Medicare Basket

Key Implications for Decision Makers

  • The debate about the basket of publicly funded healthcare services includes questions about both the content of policies and the processes to be followed in making such decisions.
  • Governments must simultaneously pursue many, often contradictory, policy goals. For example, among the many goals of a healthcare system are to ensure that individuals receive access to high-quality "needed" services in a timely and efficient manner, without consuming so many resources to threaten the ability to pursue other societal priorities. Trade-offs are essential.
  • Policy goals include elements of such "dominant ideas" as security, equity, efficiency, and liberty.
  • In terms of content, the basket debate is, in large part, about equity. Nonetheless, many important goods are left for individuals to purchase individually.
  • In terms of process, it is critical to determine when public involvement is required and for what purpose.
  • Priority-setting exercises to date indicate there is much confusion regarding the goal/s or end-state/s desired.
  • Countries that engaged in explicit prioritization for defining core services adopted one of the two following strategies. First is the "loose filter" method, whereby they relaxed the prioritization criteria and only rejected those services for which there was evidence of ineffectiveness, while continuing to fund publicly those for which there was no evidence. A second strategy was to grandfather all existing services and apply the prioritization criteria only to new services.
  • There is little or no interface between governments and private health insurance carriers and/or benefit consultants. This lack of interface appears to result from disparities in value systems between the public and private sectors, a minimal understanding of the "other," and mutual distrust.
  • An ethical public dialogue framework can help clarify the issues under consideration, elucidate the principles and values that lie behind policy options, and help decision makers analyse the issues involved and their implications by facilitating understanding of the issues through multiple lenses. It also provides politicians and decision makers with an approach for the public justification of a particular course of action.
  • The various methods of public involvement notwithstanding, experts continue to dominate prioritization efforts in these countries.
  • The framework is an approach that outlines how best to involve citizens and other stakeholders in resource allocations, keeping in mind that different populations might prefer different forms of involvement; identifies the conditions for and how to foster meaningful debates on core services and/or resource allocations; provides guidance on how and when to move forward when consensus fails; and explores mechanisms through which the interests of hard-to-reach and disenfranchised groups can be identified.

Executive Summary

Context

Our program of research posits that the effort to determine the basket of publicly financed health services in Canada involves two basic components: the policy content of such decisions, and the appropriate process to be used in making them. We accordingly place strong focus on the potential contributions of a dialogue about the definitions of equity and its relationship to the efficiency, effectiveness, and overall sustainability of the health system. The framework presented in this report should assist decision makers to accomplish two key objectives: (i) to identify under what conditions and for what types of medicare decisions the engagement of the public is a worthwhile endeavour; and (ii) to design and evaluate the process of engaging the public in discussions around medicare coverage decisions.

The program of research undertook to (a) clarify different approaches which have been taken across jurisdictions and sectors towards defining the basket of publicly funded services; (b) place these approaches within a conceptual framework which creates a common language for discussion and highlights available policy options; and (c) test the framework's usefulness and acceptability for conducting a dialogue in Canada, with key stakeholders as senior decision makers and the community.

Methods

The program of research utilized a qualitative research design in which a variety of methods are used to collect data. Embedded in the three stages around which the program of research was designed were a series of complementary "nested" projects which allowed the research team to triangulate sectors involved with the determination of services for collective funding decisions.

Results

Generally, the experiences that we reviewed did attempt to identify criteria but were unclear about how to use them. Thus, although such concepts as human dignity, solidarity, justice, equity, need, severity, necessary care, effectiveness, efficiency, individual responsibility, value for money, and acceptability were all mentioned in the processes reviewed, it was rarely clear how these particular values or principles were chosen; how to rank or order the values when there is the inevitable conflict; and how to deal with competing or contradictory values.

The countries that attempted to engage in explicit prioritization for defining core services adopted one of the two following strategies. First, they relaxed the prioritization criteria and only rejected those services for which there was evidence of ineffectiveness, while continuing to fund publicly those for which there was no evidence. This is the "loose filter" method. A second strategy was to grandfather all existing services and apply the prioritization criteria only to new services. The partial retreat from explicitness in some countries may be explained by the challenges associated with priority-setting.

Our interviews with private insurers revealed that cost-shifting strategies have increased the burden of healthcare expenditures on employers and employees. The employers we interviewed accordingly are opposed to an expansion of private healthcare to the extent it leads to increased costs, decreased competitiveness, decreased profits, and stock market-related issues. As a result, employers have implemented varied cost containment strategies related to private healthcare baskets, which in turn have shifted costs to individuals.

Our surveys of decision-making/advisory bodies asked respondents to rate the importance of a series of factors in making their coverage decisions. As predicted by the conceptual framework, equity was given a high score. However, the pattern of responses revealed a strong focus on defining equity in terms of the characteristics of the item, with particular emphasis on clinical effectiveness, magnitude of benefit, fit with the mandate of the organization, and total cost. In contrast, most variables related to characteristics of the individual clustered on the relatively unimportant side of the scale, with only severity of symptoms of the illness or the illness itself even getting scores above the neutral point. Committees tend to be dominated by civil servants and health professionals; very few require public participation. Respondents were relatively satisfied with the effectiveness of the body, its process, and the outcomes/decisions but indicated considerable room for improvement. In addition, a mapping of where decisions were being made in four Canadian provinces found considerable differences across sub-sectors, reflecting the power of particular provider groups. It was noteworthy that physician services remained within silos; in contrast, hospital services were more frequently being traded off against other sub-sectors.

Implications

It is not possible or even desirable to engage the public in every healthcare decision. Therefore, decision makers should think carefully about the issues in which they wish to engage the public and the structure of the public participation exercise. The framework should aid decision makers with the process.