The Relative Importance of Clinical, Economic, Patient Values and Feasibility Criteria in Cancer Drug Reimbursement in Canada: A Revealed Preferences Analysis of Recommendations of the Pan-Canadian Oncology Drug Review 2011-2017.

BACKGROUND: Most Canadian provinces and territories rely on the pan-Canadian Oncology Drug Review (pCODR) to provide recommendations regarding public reimbursement of cancer drugs. The pCODR review process considers four dimensions of value-clinical benefit, economic evaluation, patient-based values and adoption feasibility-but they do not define weights for individual decision criteria or an acceptable threshold for any of the criteria. Given this implicit review process, it is of interest to understand which factors appear to carry the most weight in pCODR recommendations using a revealed preferences approach. METHODS: Using publicly available decision summaries (n = 91) describing submissions and resulting recommendations 2011-2017, we extracted ten attributes that characterized each submission. Using logistic regression, we identified statistically significant attributes and estimated their relative impact in final recommendations. RESULTS: Clinical aspects appear to carry the greatest weight in the decision to reject or not reject, along with aspects of patient value (treatments with no alternatives were less likely to be rejected). Cost effectiveness does not appear to play a role in the initial decision to reject or not reject but is critical in full versus conditional approvals. There is evidence of a maximum acceptable threshold of around $Can140,000 per quality-adjusted life-year (QALY) gained. CONCLUSION: A set of factors driving pCODR recommendations is identifiable, supporting the consistency of the review process. However, the implicit nature of the review process and the difficulty of extracting and interpreting some of the attribute levels used in the analysis suggests that the process may still lack full transparency.

Physician payment methods: a focus on quality and cost control.

With rising health care costs, governments must develop innovative methods to deliver efficient and equitable health care services. With physician remuneration being the third largest health care expense, the design of remuneration methods is a priority in health care policy. Otolaryngology-Head and Neck surgeons should have an understanding of the behavioural incentives associated with different physician payment methods. This article will outline the different physician payment methods with a focus on discussing the impact on quality of care and health care costs.

Choice of treatment with antidepressants: influencing factors.

Depressive disorders place a large burden on patients and on society. Although efficacious treatment options for unipolar depressive disorders exist, substantial gaps in care remain. In part, the challenge lies in the matching of individual patients with appropriate care. This is complicated by the steady increases in the variety of antidepressants available in the market. The goal of this study is to highlight the decision processes in the selection of antidepressants by clinicians, given that most treatments have similar clinical effectiveness profiles. We conducted a systematic literature review of studies that referred to the decisions surrounding treatment with antidepressants for the treatment of non-psychotic unipolar depression. Our analysis of the literature reveals that the choice of treatment is based on a variety of factors, of which clinical evidence is only one. These factors can be categorized into clinical factors such as illness and treatment characteristics, individual factors such as patient and physician characteristics, and contextual factors such as setting characteristics, decision supports and pharmacoeconomic aspects. Illness characteristics are defined by the type and severity of depression. Treatment characteristics include drug properties, efficacy, effectiveness and favorable as well as unintended adverse effects of the drug. Examples for patient characteristics are co-morbidities and individual preferences, and physician characteristics include knowledge, experience, values and beliefs, and the relationship with the patient. Treatment guidelines, algorithms, and most recently, computational supports and biological markers serve as decision supports.

Healthcare policy tools as determinants of health-system efficiency: evidence from the OECD.

This paper assesses which policy-relevant characteristics of a healthcare system contribute to health-system efficiency. Health-system efficiency is measured using the stochastic frontier approach. Characteristics of the health system are included as determinants of efficiency. Data from 21 OECD countries from 1970 to 2008 are analysed. Results indicate that broader health-system structures, such as Beveridgian or Bismarckian financing arrangements or gatekeeping, are not significant determinants of efficiency. Significant contributors to efficiency are policy instruments that directly target patient behaviours, such as insurance coverage and cost sharing, and those that directly target physician behaviours, such as physician payment methods. From the perspective of the policymaker, changes in cost-sharing arrangements or physician remuneration are politically easier to implement than changes to the foundational financing structure of the system.

Framework for the design of physician remuneration methods in primary health care.

Economists have generated a large body of theoretical and empirical knowledge with respect to the design of physician remuneration methods (PRM). This knowledge is difficult to use for a policy maker, because of its technical nature and its fragmentation. The article brings together the scattered elements of theory and evidence into a structured framework that adds practical use value to economic theory, useful in the applied practice of policy development, design, implementation, and evaluation. The article argues that the optimal choice of PRM depends on the goals of the health care system, and on external contextual factors. Fee-for-service payments are best when the goals are quantity of care and risk acceptance. Capitation is best when the goals are collaboration between providers and delivery of preventive services and health promotion. Salaries are best when population density is low, and the goal is to recruit physicians to rural and remote areas. Blended payment models are recommended for the achievement of multiple goals. As a demonstration of use value, the framework is applied to the assessment of Canadian PRM.

Physician remuneration methods for family physicians in Canada: expected outcomes and lessons learned.

Canada is a leader in experimenting with alternative, non fee for service provider remuneration methods; all jurisdictions have implemented salaries and payment models that blend fee for service with salary or capitation components. A series of qualitative interviews were held with 27 stakeholders in the Canadian health care system to assess the reasons and expectations behind the implementation of these payment methods for family physicians, as well as the extent to which objectives have been achieved. Results indicate that the main reasons are a need to recruit and retain primary care physicians to rural and remote regions of the country, and the desire to increase collaboration, care continuity, prevention and health promotion. The general perception is that positive results have been observed, but problems are not alleviated. Blended payments have had some positive effects on preventive care delivery, collaboration, and care continuity. Salaries have provided a stable, predictable, and high source of income for physicians, thereby improving recruitment and retention. The implementation of salaries, however, led to concerns with declining physician productivity, and has brought to light a need for improved measurement and monitoring systems.

Health human resource planning in Canada: a typology and its application.

A series of group interviews were conducted with key stakeholders in Canadian health human resource (HHR) planning. Interviews revealed that innovative HHR models arose primarily in response to perceived needs at the front line. At the same time global HHR initiatives were implemented by policy makers based on population level estimates of need. A large disconnect is identified between the top down and the bottom up approaches to HHR planning. This paper makes two important contributions. First, it provides a comprehensive typology of HHR models currently being utilized in Canada. The classification of existing HHR models is a necessary first step to standardized evaluation of effectiveness of various HHR approaches in terms of improving access to care and health outcomes. Second, the creation of a new type of health care professional is proposed--the collaboration agent. The collaboration agent is to provide much needed leadership to bottom up endavours at the front line. Furthermore, the collaboration agent is to mediate between the top and the bottom, thereby improving deficient communication and funding channels.